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Letters to the Editor

From the January ACP Internist, copyright © 2009 by the American College of Physicians

Futile to whom?

I read with interest the Ethical Dilemmas column “‘Futile to whom’ challenges views on reasonable recovery,” (ACP Internist, November/December 2008) in which Douglas Van Houten, RN, describes the case of a 41-year-old woman with terminal breast cancer and lung metastases, recently in the ICU on a ventilator for respiratory failure, now re-admitted. The pulmonologist did not want to reintubate her, citing futility, but the patient wished it, to be able to spend more time with her two teenage boys, via writing notes. She was reintubated and died two weeks later, on the vent. Dr. Forrow agreed with Mr. Van Houten that sometimes, after further life support initially seems “futile”, clinicians may come to understand the value from the patient's perspective and agree to provide it.

What I found most striking is that neither writer says one word about the cost of this care.

Anyone bringing up the cost issue in an ethics/family meeting like this one would run the risk of a scowling reply that “It isn't about money. We have to do what's best for the patient.” The hospital gets its revenue, nurses and physicians are paid. And yet, the private insurer's budget takes a hit, or the Medicare/Medicaid budget is overdrawn, leading to either higher premium rates or reduction in the rolls of Medicaid. etc.

We all (me included) choose to ignore that reality, saying “We just take care of one patient at a time,” and then rail against some disreputable “bean counter down in the basement” who is lowering our reimbursements or raising patients' premiums. But the bean counter didn't spend this money, or order these tests; I did. Unless we decide as a country to accept no lid on health care expenditures and correspondingly raise our taxes to pay for unlimited health care, I submit that always putting “patient centered goals first” without even discussing cost is a potentially ruinous strategy.

Sean Stitham, ACP Member
Seattle

Dr. Forrow replies: Dr. Stitham makes an extremely important point. We continue as a society to fail abysmally in having honest discussions about how, if at all, costs should be taken into account in cases like this one. But even a “bean counter down in the basement” may have serious doubts about whether cost-based decisions should ever be made at the bedside of an individual patient. At one of our own medical center's ethics conferences, our director of inpatient billing startled clinical staff by stating unequivocally that an ICU physician should never (yes, never!) take finances into account in ICU life support decisions. I invite readers to propose a case for a future column in which limiting life support in the ICU based in part on cost is arguably the right thing to do.

Fixing primary care

As a former National Health Scholarship recipient and long time primary care internist, I believe that increasing the number of NHSC recipients is not a good solution to the primary care crisis. Taking inexperienced medical students or pre-med students and obligating them to a career long before they are trained leads to several undesirable outcomes. First is the problem of rapid provider turnover in primary care settings. NHSC docs often move on as soon as they can, some to pursue other specialties, and the patients suffer. Second is the problem of bad administration of medical sites where NHSC physicians are forced to go. Having an ongoing source of indentured physicians only perpetuates the mismanagement and mistreatment of primary care physicians in settings where there is high physician turnover. A far better approach is to offer loan repayment for primary care physicians. In that system, physicians are voluntarily coming to a site with training in a specialty which they have chosen. Unfortunately, the Federal Loan Repayment program remains under-funded has not increased its yearly payment significantly in the last 10 years.

Joseph Magee, FACP
Tuba City, Ariz.

Autism resource offered

Thank you for publishing the article “Gently does it; caring for adults with autism” [November/December ACP Internist]. The incidence of autism related disorders is increasing and with that will come an increase in the young adults and adults affected by the disorder. I suggest that the American College of Physicians take a leadership role in preparing a comprehensive educational effort that will include the medical residency training programs and the medical schools, nationwide.

You however failed to include the National Autism Association (NAA) in the listing the resources in the article. The NAA is a national organization whose mission is to provide education and services to families while supporting research and advocacy and other related matters. The Autism Safety Initiative “Found,” the Life Saver Equipment project, Family First and Helping Hands are just few of the examples of the programs offered by the NAA. The NAA has chapters all over the country. I belong to the New York Metro Chapter that is very active in serving the metropolitan area and the adjacent communities.

The NAA can be accessed on the Web.

Khalid L. Rehman, FACP
New York City

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