Rx … Must It Be Cure vs. Care?, Part I

GUEST: Dr. Diane E. Meier
VTR: 06/22/2006

I’m Richard Heffner, your host on The Open Mind. And my guest today, a distinguished professor of geriatrics, medicine, and medical ethics, is Dr. Diane E. Meier, Director of the Hertzberg Palliative Care Institute and the Center to Advance Palliative Care at the Mount Sinai School of Medicine here in New York.

Now, interestingly enough, when I first discussed palliative care here a dozen years ago with that wonderful physician’s physician, Dr. Kathleen Foley, then head of the Pain Service at Memorial Sloan Kettering Cancer Center, very little formal attention was being paid to it at both hospitals and medical schools around the country. Now, however, most medical schools require instruction in the field, and many, many more hospitals have palliative care teams.

And yet I suspect my guest today isn’t yet satisfied with the extent or the quality of palliative care in the United States. And I want to ask her to what extent our problem in this area may have to do with something of a dichotomy between cure and care in the very culture of American medicine.

MEIER: I think you’ve put your finger on it. It’s very difficult for us to hold two goals or two concepts in our minds at the same time, both as patients and as physicians. And the two goals that we need to learn to hold in our minds at the same time are the desire to live as long as possible, along with the desire to live as well as possible. And …

HEFFNER: When did it happen that care, however, and cure began to be recognized as two themes that had to be considered, both by the patient and by the physician?

MEIER: Well, I think, if you think about the history of medicine prior to World War II, prior to the 1950s there was very little that medicine and physicians could do to affect the course of an illness. Most people died of pneumonia or tuberculosis. Most people died rather suddenly in association with an infection.

But after the advent of antibiotics, sulfur and penicillin and in the 1950s and the subsequent growth of modern medical technology which enabled us to prolong lives of people with very serious chronic diseases like heart failure, or Alzheimer’s disease or emphysema or kidney failure, dialysis, for example, we lost sight in many ways as a profession of the fundamental ethos and value of the profession to care. And to always be present for the patient.

As Francis Peabody said the secret in caring for the patient is to care for the patient. And we, we became entranced, both our patients and we, as physicians, became entranced with the potential of modern medical technology. And I think we’ve all been caught up in this sometimes naïve feeling that with enough research, enough investment in the NIH, enough pharmaceutical company research that all diseases can be cured and that death itself could be defeated.

And if you walk through a modern American large teaching hospital in the United States you couldn’t be blamed for thinking that the aim of the hospital is to defeat death and to prevent death from ever happening. And yet I think if we reflected on the what kind of a society it would be if no one ever died and if all diseases were prevented, we might ask ourselves whether that’s really an appropriate social goal.

HEFFNER: Well, with that in mind, how difficult … how easy is it for you to deal with your medical colleagues in terms of your interest concerning patient care … not a painless end of life, or, indeed, if I understand correctly … a dozen years ago it was end of life that was a major concern.

MEIER: Right.

HEFFNER: And today?

MEIER: Today we are trying very hard to separate the notion that palliative care is, is for the dying. Palliative care is for anyone with a serious illness, no matter how long they may have to live with that illness. Most people today have the disease from which they will die for more than a decade.

Most people with cancer live for many, many years before they die either of their cancer or from something else. Same is true for heart disease which is the leading cause of death in this country. Most people with heart disease live for several decades with significant vascular disease. And yet the quality of that life is seriously affected by these many chronic illnesses.

People live with pain, with shortness of breath, with fatigue, with difficulty sleeping, loss of energy, loss of appetite. And all of those things can be improved with the combination of their regular primary care physician and palliative medicine expertise. Our focus in palliative medicine is to do everything humanly possible to make the quality of that extra life one worth having.

And, so, palliative care is not at all linked to end of life, although we also take care of people who are dying. But many of our patients are not anywhere near to the end of their life, but are living with a lot of complications from bad diseases. They’re alive, and they’re going to be alive for a long time, but we want to make that life as good as it can possibly be.

HEFFNER: Well, of course, it does raise the question … I, I was quite taken … a) by the title of the article in January 2006 that you and Dr. Quill wrote … “The Big Chill: Inserting the DEA Into End of Life Care.” Has that been a problem of particularly high dimension for you?

MEIER: There is the actuality of the problem and the perception of the problem have to be distinguished. Many physicians are afraid that if they write prescriptions for controlled substances, like opioids, morphine, for example, or oxycontin, for example. Or medicines for anxiety like adavan or valium type drugs that the government will be watching over their shoulders and will come and check on them and review their charts and query them.

And so some physicians have actually made decisions not ever to prescribe those medicines, rather than deal with the possibility that Big Brother will be watching them. Because people have to make a living, they have to pay back their medical school loans. They have to pay the rent. They have to sent their children to college. And the fear of government oversight in this area is, I believe, disproportionate to the actual risk.

But last year there was a serious effort on the part of the current Administration to give new powers to the Drug Enforcement Administration that actually would have enabled them to come in and second guess the medical decision making of physicians taking care of people who died.

So, for example, the assumption would be that a patient with advanced lung cancer and pneumonia who died in an Intensive Care Unit and was receiving medication for shortness of breath or pain during his or her last few days of life.

The DEA’s assumption would be that the physician was trying to kill the patient with the pain medicine or the medicine for shortness of breath, rather than that the patient died of their underlying advanced cancer or advanced infection.

The consequence of that, of every time you write a prescription in a patient who is dying to relieve suffering, that it would be assumed by the government that you were somehow doing something wrong, would have had a devastating effect on physician’s ability to control distressing symptoms in people who are nearing the end of life.

HEFFNER: Well now is that a perceived problem or a real problem?

MEIER: It would have been a real problem had the Administration and the Supreme Court given that power to the Drug Enforcement Administration.

As it happened the court decided that this was not an appropriate power for the DEA and that oversight of medical practice belongs as it has for decades, with the states.

HEFFNER: But a period hasn’t been put to that question or statement, has it? Are we at the end of a fear, of a period of necessary fear of government action?

MEIER: I don’t think we can ever be at the end of it. We’re … we have a “Just Say No” to drugs culture here and a great deal of difficulty achieving a rational balance between the very important goal of preventing diversion of appropriately prescribed drugs to people who sell them on the streets, to people who are using these drugs for psychiatric addiction as opposed to real medical problems.

But we shouldn’t let our concern with diversion, drug diversion and addiction prevent us from treating the overwhelmingly larger number of people living with legitimate medical illness and very significant symptom distress. We need to manage to do both. And it in a society as sophisticated and advanced as ours, we should be ashamed of ourselves that we haven’t figured that out yet.

HEFFNER: And would you say the same about medical schools today? Are they doing enough along these lines.

MEIER: Well, let’s see. I graduated from medical school in 1977 and then did three years of residency and two years of fellowship in geriatric medicine, so that’s nine years of education after college. At that time I did not receive a single lecture on pain management. I did not learn anything about the management of pain, shortness of breath, agitation or confusion in people who are sick, nausea …common, distressing symptoms that all people experience when they have a serious illness … to one degree or another. It simply was nowhere to be found on the curriculum.

And it took me until I was in my forties to basically decide that just because I hadn’t been trained in these things didn’t mean I shouldn’t go out and learn them and establish a program that would teach others to know how to assess and treat distressing symptoms like pain and other problems.

Today what is it, 25 years later, nearly 30 years later, after I graduated from medical school, every medical school is mandated to teach this stuff. But that didn’t really happen until the year 2000. Prior to the year 2000 there was very little to no content on symptom management and palliative medicine in the medical school training.

Now, for those of you who have physicians who are “baby boomers” you can assume that they, too, have not been trained in this content. And it’s not their fault, it’s not because they don’t care, it’s not because they’re not concerned about their patients’ symptom distress; they simply never got it in their training.

We all learned how to manage an acute heart attack … what to do, it’s automatic, we don’t even have to think about it. We all learned how to manage insulin dependent diabetes, how to manage high blood pressure. These things were drilled into us repeatedly. The same is not true for pain and other symptoms.

So, it’s important for the patient and the family to advocate for themselves, with respect to getting good management of pain and other symptoms because the physician is typically very handicapped in that regard because of lack of training.

HEFFNER: May I ask you to define the term “advocate for themselves.”

MEIER: Well, it means that it’s important for patients and families to remember that they are the customer. And that physicians and hospital exist to serve them. And not to be so fearful of … perhaps disapproval or negative reaction from the part of people taking care of them … physicians, nurses, other consultants. That they’re unable to speak the truth to power. That is to say, “Here’s what I’m feeling. What can we do about it?”

HEFFNER: You mean doctors aren’t gods?

MEIER: No, doctors aren’t gods. And doctors really do … the overwhelming majority are in the profession of medicine because they … we want to help people and we want to relieve suffering and we want to be healers. We cannot do that without hearing the truth from our patients about what’s distressing them and what they need help with.

And I think if a given physician doesn’t have the skill set because he or she was not trained in management of symptom or other distressing problems of serious illness, the patient needs to ask the physician, “Is there a palliative care program at our hospital? Can you refer me to some one who can help us as we negotiate this illness?”

And this reminds me of a New Yorker cartoon where there’s a photograph of a doctor in a white coat and a stethoscope, speaking with a patient, sitting at a desk, next to him, and the doctor says to the patient, “I don’t know how to tell you this so I’m going to send you to someone who can.”

Now clearly this … the New Yorker editors thought that this was a bad doctor, that … you know … didn’t know how to communicate …

HEFFNER: Right.

MEIER: … those of us in palliative medicine think this is a really good doctor because he knows what he doesn’t know. And he knows what his patient needs and he makes the appropriate referral to make sure his patient gets the kind of quality care he or she deserves.

Now I’m a geriatrician and an internist. My patients often have surgical problems, cardiac problems, oncology problems. I’m not arrogant enough to think I know everything about surgery or cardiology or oncology. I send my patients to the best consultant I can find to make sure they get optimal care in each of those categories. Similarly I expect my colleagues to refer to me when they have a patient who’s dealing with a complex distressing, serious illness.

HEFFNER: Two words … do they?

MEIER: Increasingly, they do. I would say the biggest problem that palliative care programs are facing in hospitals around the country, and increasingly the majority of hospitals do have these programs, is that they are drowning in work. And can’t keep up with the demand. And are not staffed adequately to keep up with the demand.

And that’s part of what happens in a social change process. That as a new innovation develops and is picked up more and more and more, figuring out exactly what the frame is, how many doctors, nurses and social workers per how many patients at any given time, are all in flux. And those things are being developed and being thought through and being studied now. But, as I travel across the country, the biggest problem I see is not that physicians are not referring, but that they’re referring so much, that these palliative care teams are at risk of burn-out.

HEFFNER: My understanding is that a larger and larger percentage of medical students are women. Does that auger well for the growth of palliative care?

MEIER: I think it depends on who you ask. But, in my opinion …

HEFFNER: I’m asking you.

MEIER: (Laughter) In my opinion, the answer is “Yes.” At Mount Sinai now over half the class are women and, and yet every year as you look at the entry grade point averages, the entry MCATs, those are the tests you have to take to get into medical school …they’re higher and higher and higher. Women are getting in based on merit, not based on any kind of attempt to balance … or be prejudiced.

HEFFNER: But does that auger well in terms, particularly for the growth of palliative care?

MEIER: I will tell you that in terms of how people vote with their feet there seem to be more women in the field of palliative medicine, in the field of geriatric medicine, in the field of pediatrics. I don’t think that means that physicians … male physicians … care less, there just seem to be differences in people’s preference … more male physicians are surgeons than women.

But increasingly …yesterday I gave surgery Grand Rounds at Mount Sinai … I’ve never seen this before … certainly a third, if not nearly half of the residents in the program are now women. And, superb … sharp as tacks, really bright, highly capable technically as well as intellectually. So I think a lot of those old saws …

HEFFNER: MmmHmm.

MEIER: … about women “go into the caring profession,” men go into the “a chance to cut is a chance to cure” professions are falling down and it’s a work in progress. It’s changing.

HEFFNER: Let’s continue along these lines for a moment … women in medicine. How do you see that division a decade from now? Two decades from now?

MEIER: I think there are many changes occurring in how government and private insurers pay for health care. And there’s not … and these changes are not finished. But increasingly it is very difficult for physicians to make a living in a primary care specialty.

Because the people who are well reimbursed, are those who do very complex procedures, like surgery or angioplasty or cataract operations. And those of us who listen and talk and think … and help patients and families sift through enormously complicated interacting medical problems and decisions and drug/drug interactions get paid a very tiny percentage as opposed to physicians in procedural specialties.

The result of that is that increasingly the best and the brightest are not entering primary care fields. What we have here is a payment system that does not reward what are called “cognitive specialties; thinking specialties” … internists, pediatricians, geriatricians, but that highly rewards procedural specialties and medical school costs a huge amount of money.

Many medical … the average debt for medical students coming out of non-state schools, private schools is over $200,000. And how is a young physician going to pay back that debt, get married, have a family, buy a house in the suburbs and, and … without becoming a neurosurgeon? Or a plastic surgeon? Or an interventional cardiologist? They really … we don’t give these young people any choice. So until the policy shifts to recognize that what society really needs is a lot more cognitive specialists who can deliver primary care and spend the time that’s necessary actually listening to their patient, we’re going to have everyone running toward the highly procedural specialties because frankly they don’t have any choice … financially.

This is a fixable problem if we can get the people in positions of power and health policy at Medicare and the private insurers to really change how they pay for services.

HEFFNER: What’s your bet?

MEIER: As is often true in health care, it usually takes a crisis before anything changes fundamentally. What happened with the Clinton health plan is a, is a good object lesson there. The aging …the current aging of our population, which is unprecedented in human history … that we’re now at a point where over … within a few years … over 20% to 25% of the US population will be over 65. That’s never happened, since humans first appeared on the planet.

And it’s a very profound shift. And what is the meaning of a life? What is the purpose of a life? And what are the aims of medicine? The aims of health care? And, writ large, what are the aims of a society? Is the aim of society for every single person to live into their nineties with advanced dementia? Or is the aim of a society also to make sure that every child has health insurance? And that every school is well funded? And that air pollution is controlled?

We really need to balance our goals here and, as a society, we have not addressed the, the shift in realities that the aging of the population has presented to us.

HEFFNER: Does that mean rationing?

MEIER: Ahmm, rationing would be a harsh word, but it does mean difficult decisions. Because we don’t have infinite resources as a society. And if you look at what percent of the GNP is going to health care and what percent of health care expenditures goes to people who are not going to live very long and have many complex illnesses, you have to ask … if you were a new born baby would you think this was a reasonable distribution of resources.

We now have nearly 50 million people in this country with no access to health care at all. No health insurance. And yet infinite utilization of resources in very complex, very seriously ill, frail older adults and you can’t have it all. Unfortunately. I wish we could.

HEFFNER: And this, this conflict in culture …

MEIER: MmmHmm.

HEFFNER: Or the medical care versus cure …

MEIER: MmmHmm.

HEFFNER: … that just exacerbates the whole business, doesn’t it?

MEIER: Follow the money. We pay physicians to do highly complex, well reimbursed procedural specialties, so that’s what they do. And that’s what patients get. And it costs a lot of money.

HEFFNER: And technology?

MEIER: Yeah, well … you know … for example … the Medicare has now approved PET scanning for the diagnosis of dementia. Now I’m not sure why I need … I have never ordered a PET scan to diagnose dementia. The diagnosis of dementia is a clinical diagnosis. If I was doing research on dementia I might order a PET scan for research purposes. But the reason for that is that the people who do PET scanners lobbied very effectively in Congress and managed to get their procedure covered under Medicare. And many people are making a huge amount of money because of that.

Is it going to make any difference, whatsoever to the incidents and prevalence of Alzheimer’s disease? None. And, yet, that’s how our system works right now.

The people who stand to make a lot of money from a given procedure or a given imaging study, or a given drug, put huge amounts of money into lobbying in Washington, DC. And that leads to approval of whatever their product is for Medicare reimbursement.

And once Medicare approves funding for these things, all the private insurers are pressured to do the same. That’s how health policy is determined in this country at present.

HEFFNER: It’s not a very pretty picture, is it?

MEIER: No, it’s not. But it’s important that people know about it because this is a democracy and if people recognize how little coherent, rational oversight there is, of how health care resources are distributed … based on need and effectiveness, then they might vote differently.

HEFFNER: Wouldn’t you be concerned … we have a minute … minute and a half left … wouldn’t you be concerned with being put in the position to make the decisions as to where the resources should go?

MEIER: I don’t think that’s the job of the physician. The job of the physician is to advocate for his or her patient. And to help his or her patient decide, among the alternatives they have, which one is most concordant with their wishes or values.

HEFFNER: But who, other than the physician knows what you’ve just said?

MEIER: If I’m in a society that says, “We’re going to pay $5,000 for a PET scan for a patient with Alzheimer’s disease, and Medicare is going to cover it … so there’s no incentive not to do it … only the taxpayer feels it. The patient doesn’t feel, the doctor doesn’t feel it … why not? The patient sees the ad on TV … “Doc, I’m having trouble remembering my appointments, why don’t you send me for a PET scan?” Do I then spend 20 minutes arguing with this person that he or she doesn’t need a PET when I have 10 people waiting in the waiting room? Many physicians just order the PET scan.

HEFFNER: Dr. Meier it took so long for me to be able to find your time available for such a program. I hope that it doesn’t take as much time for you to come back here because there are obviously so many of these issues that need to be discussed and understood.

One thing I want to ask you … is the patient … 30 seconds … is the patient … as some of the doctors who are fearful … who have been fearful of prosecution … is the patient a barrier, sometimes, to the proper use?

MEIER: There are societal barriers, physician barriers and patient and family barriers. There’s a lot of myths around the use of appropriate opiod analgesics for pain. A lot of fear of psychiatric addiction. That almost never happens in medically ill people. People who are medically ill and in pain, can taper off their pain medicine in a matter of days when they no longer need it.

HEFFNER: That’s one of the subjects we going to have to discuss. Dr. Meier thank you for joining me …so much for joining me today on The Open Mind.

MEIER: It was a pleasure, thanks for having me.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time, and for transcripts, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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