In virtually every analysis concerning the pros and cons of America’s so-called healthcare ‘system,’ money is front and center on almost every list assigning blame for our less than stellar performance. In tough economic times, when millions of Americans do not have insurance or access to care, profits reported by hospitals, pharmaceutical companies, and insurance providers, to name a few, and invariably, compensation for the executives and physicians who runs these businesses and care for the patients, are lightning rods for the chattering pundits, lawmakers and state and federal regulators. New York, for example, recently proposed that not-for-profits that receive public money must limit the base salaries of its chief executives to less than $200,000.
The debate becomes inflammatory when it turns to compensation of physicians in clinical practice. There are anecdotal stories aplenty of how physicians perform unnecessary tests and interventional diagnostic procedures. Cardiologists in some markets are singled out for the numbers of stents they implant. Oncologists get their share of criticism for, some argue, unnecessary administration of chemotherapy – and their failure to refer to hospice – even when the case is clearly hopeless. Critics are quick to bundle these physicians in with the greedy Wall Street bankers and unscrupulous mortgage loan originators who were in it for the money, damn the ethics or the consequences.
Are their widespread abuses? Yes. And it includes all specialties. A senior partner in a highly respected radiology group recently decried the attitudes of far too many young physicians who are more concerned with the compensation and time off than the patients or the quality of the practice. There is little or no attempt to mask their real priority, and it is not the patient, he sadly complained.
But there is another side to this story, and it deserves thoughtful consideration.
Leeat Granek, a healthcare psychologist and post-doctoral fellow at Toronto’s Hospital for Sick Children, revealed in a Sunday New York Times Op-Ed piece that in the case of some physicians, what appears to be wasteful or inappropriate intervention, may be driven by a doctor’s grief in treating a terminally ill patient.
In a study on the issue of physician grief, Granek and her colleagues found that half of the doctors who participated in the study admitted that “their discomfort with their grief over patient loss could affect their treatment decisions with subsequent patients, leading them, for instance, to provide more aggressive chemotherapy, to place a patient in a clinical trial, or to recommend further surgery when palliative care might be a better option.”
“One oncologist in our study remarked: “I see an inability sometimes to stop treatment when treatment should be stopped. When treatment is futile, when it is clearly futile.”
The study indicated that physician grief in the medical context is considered shameful and unprofessional. “More than half of our participants,” Mr. Granek writes, “reported feelings of failure, self-doubt, sadness, and powerlessness as part of their grief experience, and a third of the physicians talked about their feelings of guilt, loss of sleep and crying.
“Unease with losing patients also affected the doctors’ inability to communicate about end of life issues with patients and their families. Half of our participants said they distanced themselves and withdrew from patients as the patients got closer to dying…”
The study concludes that virtually all physicians want what is best for their patients, but in the case of death and dying, most physicians are ill-equipped to help their patients. Medical schools must shoulder a lot of the blame. They rarely provide training that will help new physicians deal with these and other non-clinical issues. But society – patients and their families – must also accept responsibility. The study said that physicians “are right to put up emotional barriers: no one wants their doctor to be walking around openly grief-stricken.”
There is much work to be done in cracking down on waste and fraud in healthcare. There are clearly many professionals who are gaming the system for huge financial gains. But in righting these wrongs we should not lose sight of the fact that the majority of the physicians we place on a pedestal, especially in end-of-life cases, are just ordinary people with special knowledge and skills. They have feelings and they grieve, too.
© 2012 John Gregory Self