Stewart v. McCaughey

[tongodeon]

I really enjoyed the last Daily Show before their 3 week break. Not because of Jon Stewart - he's usually good but I actually think he was wrong about a lot of stuff and didn't do well even when he was right. I liked his guest Betsy McCaughey. I ended up watching the entire interview twice all the way through, not counting extensive rewinds and

Comments

I make it personal...

[redstapler]

My mother died last month of terminal cancer.

She was lucky that she was married to my father, a man of means, whose employer offers comprehensive health insurance.

That she was lucky, also, to have my father as an advocate for her.

That she was lucky we have close family friends in the medical profession who could advise her and my father.

That she was lucky she was able to choose to go to hospice and die peacefully.

I've also seen what happens when people aren't lucky, and it infuriates me.

I also know too many people who keep bad jobs because of the health benefits, or who pass up excellent jobs because there are none.

Re: I make it personal...

[tensegritydan]

I'm sorry to hear about your mother. My mother died from cancer about 2 years ago in what sounds like very similar circumstances, so I agree with you 100%. I feel that everyone should be able to face the end of life with the level of care and respect that she was lucky enough to have access to. Peace to you.

[cdk]

I feel like I must be missing something. I'm not sure what sort of document I could create that would let someone withdraw medical care from me when there's any reasonable expectation that I can make those medical care decisions myself. How does "adherence to" an "end-of-life plan" make any sense from the perspective of the person who made the plan? I mean, I can create a legal document that will take effect when I am no longer capable of making my own decisions, but the only way I can fail to "adhere" to that document is to create a new document that does the same thing.* But in that case, I'm still adhering to my end-of-life plan, it's just not the one I created earlier. If I'm for some reason incapable of making decisions about my own medical care, the only way I could fail to "adhere" to my "end-of-life plan" would be to spontaneously become well. I don't understand what I, as a potential patient, could do to "change my mind". I really feel like I must just be missing something - the only way I can find to interpret the "adherence

[tongodeon]

The health care document says:

For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life- sustaining treatment.Basically there's an incentive for coming up with a plan, and there's an incentive for sticking with the plan

[cdk]

I don't know how to make sense of the phrase "orders for life-sustaining treatment" except in the context of a living will. Why would I make a document that says, "In the event that I require life-sustaining treatment, and am perfectly aware, communicative, and able to participate meaningfully in health care decisions, please terminate me regardless of my wishes"?

[tongodeon]

Why would I make a document that says, "In the event that I require life-sustaining treatment, and am perfectly aware, communicative, and able to participate meaningfully in health care decisions, please terminate me regardless of my wishes"?

You wouldn't, and the doctor wouldn't, and that's not what would happen, and that's not what the document says to do. I have no idea where you're getting this from, but nobody except you is saying that.

[hugh_mannity]

The current system already has that sort of incentive for doctors. Most HMOs are moving towards "Pay for Performance" in which a doctor is judged and paid on his meeting the various HEDIS quality measures

[tongodeon]

We're not robots. People are not interchangeable.

So this deviates off to a completely different subject that I've been meaning to post about, but there's a lot of research on "depersonalization". It turns out that, although we are not interchangeable robots, medical care actually works better if we're treated that way. If you actually go through the standard diagnostic treatment pathway rather than letting every individual doctor decide which parts of every individual patient's self-reporting they're choosing to report.

Basically, although we're not identically interchangeable robots, the stuff that actually contributes to recuperation is reasonably identical whereas the stuff that's different is more often than not superficial, irrelevant, and distracting.

[tensegritydan]

You are absolutely right. There's a good chapter in Malcolm Gladwell's Blink about the power of diagnostic guidelines

[tongodeon]

I'm trying not to let this can of worms get open too much but let it be clear that rating individual doctor quality is difficult, and lay-patients rating doctors is even more difficult since they typically base their decisions on superficial details rather than the actual care. And, of course, not all incentives will be intended and some people will be trying to game them. It's a hard problem, but not one that we can just walk away from as long as we're still made of meat.

[ikkyu2]

The end of life discussion is completely mandatory in my line of work, which is clinical neurology. I probably have it twice a week when I'm on hospital duty. When peoples' brains are irrevocably destroyed but the heart and lungs are still operating on support, you pretty much have to spend an hour - sometimes 8 hours over the course of a couple weeks - educating the family on what happened, what to expect, and how to make the decisions that WILL BE made one way or another in the coming days. (It's definitely that old Rush line about how if you don't decide, you've still made a choice

[ikkyu2]

As far as physician ratings go, I only have one point to make

[tongodeon]

I will game any system designed to tie my clinical performance to my payment, with the express goal in mind to maximize my payment.

I have no doubt that this is true in all cases, including the one where no performance metric exists. If there are government-imposed performance metrics you're going to do certain things to game the numbers which end up getting reported. If there are private, free market performance metrics like Yelp or RateMDs.com you're going to do certain things to the numbers that they're reporting. And in the absence of any reporting at all you're going to do things that you wouldn't do if there was a system that gave reports for what you were doing.

I completely accept that no system of regulation or reporting is perfect and that all rules will end up producing unintended consequences, including no rules at all. Historically, the consequences of there being no rules at all are the main reason why we've got rules now, and I'm not prepared to let some impossible perfect un-gameable hypothetical system become the

[ikkyu2]

What I *don't* recognize is what this has to do with the creation of or adherence to end-of-life orders.

Nothing; two comments, two totally separate issues, which was why I left them as two separate comments.

Although I think if it takes me an hour to sit down and counsel a patient and their relatives about end-of-life directives, why should that be free, when I get paid to sit down and counsel them about, say, tingling feet? These are useful things that docs do. We've already gone a long, long way down the road of "if it ain't a procedure, it don't get paid." The result: brainless, scalpel-happy O.R. drones dominate the medical landscape to the tune of billions per year; thoughtful, cognitively active docs who are thinking hard about how to benefit their patients go right out of business. If you are in favor of single payer, you have to think about these issues because the single payer will be the decider of what is paid for.

[eejitalmuppet]

Over the last 10 years, we've had an excellent example of gaming the system over here