Rx … Must It Be Cure vs. Care?, Part II
VTR Date: June 22, 2006
Dr. Diane E. Meier discusses conflicts in medicine.
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GUEST: Dr. Diane E. Meier
I’m Richard Heffner, your host on The Open Mind. And once again today, my guest, 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.
Though most medical schools require instruction in palliative care now, while few did just a few years ago, and many, many more hospitals have palliative care teams now, Dr. Meier and I spoke last time about much to be done still in caring for patients in pain, particularly in terms of the culture of American medicine.
And I’d like to pick now up where we left off then. Talking about doctors and patients … I asked you about patients’ attitudes and you indicated that there still is a barrier. You indicated there are a number of barriers to the appropriate use of palliative care.
HEFFNER: How do patients come to understand what is available to them?
MEIER: Patients and physicians are in an educational … a mutually educational relationship. The physician cannot care for the patient without learning from the patient what they are experiencing. The patient cannot get good care without learning from the physician, the pros and cons, the benefits and advantages, the harms and disadvantages of every treatment.
There is no treatment that has no risk. I mean we’ve been reading about Tylenol and liver failure, for example. We’ve been reading about bleeding problems with aspirin, things that were thought of as trivial and of no risk, also carry risk. Opioids, pain medicines like morphine are the best analgesics we have. They are incredibly effective for the relief of pain and when used properly by physicians and nurses who know how to administer them and know how to manage their side effects, they’re also quite a bit safer than many of the other analgesic medicines they have … we have on the market.
Unfortunately there’s this myth out there that these drugs are very dangerous, that people die from them, that they’ll become addicted to them. And while those things happen … rarely … as they do with any medication misused or abused or dosed incorrectly; the vast majority of the time, with appropriate medical management, these medicines are extremely safe.
So, it’s interesting to me and maybe it has something to do with the Puritan roots of our society that we recognize that all other drugs carry side effects and toxicities if they’re used inappropriately. But we still use them because we recognize that their benefits outweigh their risks most of the time.
In the case of opioids like morphine, all we focus on is the risks, and not the benefits. Why? Maybe because somehow we’ve been inculcated in our culture to think that suffering is good for you.
HEFFNER: Well …
MEIER: That pain is good for you and that it’s not important to relieve pain. And you can only say that, I have to say, if you’ve never been in serious pain. People who have been in serious pain understand how devastating it is; how, in a way, life threatening it is because you can’t function, you can’t eat, you can’t sleep, you can’t interact, you can’t concentrate. It’s worse than many other diseases … severe pain.
Mmm, so it’s easy to say that pain is unimportant when you’re not in pain yourself. But when you’re in pain yourself and its significant, you recognize …
HEFFNER: How good are we … you use the word “recognize” and you were going to talk about recognizing, I’m sure … recognizing the validity of using medications that can relieve pain. How good are we at measuring the pain we feel?
MEIER: Well, that’s another interesting problem because of our technology focus … hyper-focus. Pain is subjective. If I stuck myself with a pin and stuck you with a pin … and each of us were asked to rate that pain on a scale of zero to ten with zero being no pain and 10 being the worst imaginable pain … we would probably come up with different numbers.
That doesn’t mean that one of us is an exaggerator and one of us is an under-reporter, it means that people experience pain differently. So what that means in terms of teaching for physicians and also patients, is that the pain is what the patient says it is.
If the patient says the pain is a 9 out of 10, then it’s a 9 out of 10. If a patient … and this is one of the things that really requires training, because you’ll see physicians say, “She shouldn’t be having that much pain four days after an operation, so I’m not going to treat it.” Because four days after an operation the pain should be better.
And … but each person is different. Some people are 6’ 6”, some people are 4’ 9”. We don’t blame the 4’ 9” people for being 4’ 9”; people experience pain in hugely diverse ways. So what physicians need to learn and need to teach their patients and families is that the pain is what the patient says it is. And that we treat based on the patient’s report. There is no other way to assess pain.
So for example, if I have a patient who says, “The pain’s a 9 out of 10”, I will say to the patient, “My goal for you is to have that pain consistently under a 5.” And you tell me when we get it consistently under a 5, whether that’s an acceptable level to you.
And remarkably most people will live with pain at a 5, which to me sounds way too high. Because of side effects, concerns about side effects and because people are courageous and tough. And they put up with a lot of distress. But they don’t need to be at a 9 or a 10 level.
And, in fact, it’s bad for their health if they are. So we work together and always ask, “Where is your pain today? What’s the number? Where is it when you’re sleeping? Where is it when you’re trying to walk? Where is it after meals? Where is it when the nurse is changing your dressing? And try to adjust the medication so that we can prevent the severe pain.
For example when someone has had hip fracture surgery … they maybe very comfortable lying in bed. And not need any pain medicine. But when you try to get them up for physical therapy, which is critically important for people to recover … that they get up and they move … they have so much pain that they refuse to walk.
So what do you do in that situation? Give someone pain medication around the clock? No. You give someone pain medicine 30 minutes before physical therapy. So they participate.
Now, obviously, you can hear from what I’ve said that this requires a conversation. And time spent listening to the patient and hearing from the patient what they need. Then and only then can you prescribe appropriately, safely and effectively. For the patient’s pain.
HEFFNER: The late Lew Thomas once said to me that it was the nurse who so much better could estimate, understand a patient’s pain than the doctor. Why?
MEIER: Well, again, I would say it depends. It depends on the nurse. It depends on the doctor. But …
MEIER: … doctors typically spend much less time at the bedside. Much less time listening. Much less time in contact with the bodies of their patients. They’ll come in, ask a couple questions, listen to the heart and the lungs, shake hands and leave. The nurse on the other hand is in that patient’s room, at that patient’s bedside many times during the day … is the person who sees what it’s like for the patient going through the dressing change. Because she’s doing the dressing change. Is the person who sees that the patient repeatedly refuses to participate in physical therapy because of pain. The doctor’s not there when these things are happening. The nurse is there.
So what’s the trick here? The trick is that the doctor should listen to the nurse because the nurse has the eyes and hands on the experience of the patient. The physician typically doesn’t. That’s why we’re a team, that’s why we work together.
HEFFNER: Do you know with all of your upbeat presentations, and you are a very upbeat person, I despair as I listen to you, as I realize what it was, as it sinks in what you were saying in our last program together about the dollar and its dominance in this …where it goes, decides where medicine is going because it isn’t going in the direction that you’re now talking about. It isn’t going to time, to conversation, to dialogue, to questions.
MEIER: I’m hopeful and the reason I’m hopeful is that I’m a Baby Boomer and I have parents who are facing all kinds of medical problems associated with being older. And for whom I am trying to help them … with dealing with this health care system … in quotes … health care chaos, would be a better term.
And I think others of my generation who are, you know, in leadership positions throughout society, who typically vote, who are used to having our way … we want our Mocha Frappachino just so … that we’re creating a radicalized … or informed voter block because of the Baby Boomers experience with their own parents, with their own and their friends or colleagues illnesses that we’re going to see a much more informed society voting in ways that will bring the necessary changes to health care.
I mean when 50 million people don’t have insurance, virtually every American family knows someone that doesn’t have any health insurance. That’s … it’s an embarrassment to our nation … the only other leading nation …the only other first world nation in the world that doesn’t have universal access to health care is South Africa. We can do better.
And I think we are now at a point where the political power of the Baby Boomers and their parents, as voters, may be what we need to get some changes in place.
HEFFNER: But the attractiveness of the investment in technology is so overwhelming … the, the … ahem, the key to everlasting life … I really don’t see how you Baby Boomers even with us old fogies in the background are going to be able to beat that. When does the theory of medicine … when does culture in medicine change again so that we are not finding even the request that so many billions and trillions be invested in the machinery, in the technology … it does seem to me that it is at the medical school level.
MEIER: Well, it’s …it’s all these forces together … have to be aligned to get real social change and to get innovation to stick.
And that’s … it has to change at the medical school level, but that won’t change until how physicians are paid gets changed. Because until physicians are paid a living wage for doing the kind of medical practice we’ve been talking about here … they will continue to become surgeons and interventionalists.
That is something that can be changed at the government level. That is policy. And no device manufacturer, or drug manufacturer … I mean they can try to prevent that through lobbying, but an informed populace is the best way to change that. And I’m hoping that what failed with the Clinton Health Plan … that some … a new attempt would be more likely to succeed in the next 10 years because, frankly, we are a much more “burned” and sophisticated as voters than we were 10 to 12 years ago on these issues.
HEFFNER: You talked about “First World country”, what is the situation in the other countries of the world that are advanced economically, technologically?
MEIER: Unfortunately, they’re all rushing to catch up with us (laughter) in terms of demand for marginally beneficial, but very expensive drugs and devices and procedures and imagining studies.
And countries that have a national health plan are really struggling to balance the importance of making sure that everyone has access to some health care with the need to make sure that someone who needs a total hip replacement doesn’t wait three years to get it because there’s a queue, there’s a waiting list and there’s a limit on the number of procedures that can be done. And that is the case in Canada, and that is the case in Great Britain.
On the other hand, they don’t have 50 million people with no health insurance. How do we weigh those goods? How do we balance in a way so that everyone’s covered and not everyone gets everything they want immediately, which is something that, as a society, we’re going to have to learn how to accept.
And I agree that that’s not our character as a society, we’re very much about life, liberty and the pursuit of happiness, as opposed to the greater good. But I think we need to evolve towards a society that thinks about the greater good. And that’s going to require leadership that talks about it.
HEFFNER: If we don’t evolve that way, if the American devotion to technology …
HEFFNER: … maintains itself, what do you see as the pattern of health care in the future. No what you want …
HEFFNER: What do you think it will be?
MEIER: Oh, more of what we’re … what, what I’m afraid of is more of what we’re already seeing, which is de facto rationing. And that people who have insurance or who can pay out of pocket get and people who are costing the system too much, and there is an income connected with them, are just marginalized.
And you see this pattern now already because many hospitals across the country are realizing that they cannot get paid enough for the care of very complex patients with dementia and infections to make it worth their while to want to encourage those patients to come to them.
Increasingly they want the cardiac patients, the cancer patients, the surgical patients and just kind of wish that the regular patients with pneumonia would go somewhere else. Because the reimbursement is so much better for those high procedural specialties and hospitals are really struggling now with what is their community mission, when they cannot meet payroll if they don’t start to invite in the more high reimbursed patient procedures and thus make it more and more difficult for the low reimbursement patients and procedures to get in.
HEFFNER: Do you think it will lead to … you mentioned rationing … you think that literally the high technology treatments will be phased out for those who cannot immediately themselves pay for it.
MEIER: I think we have a long way to go to start paying for things that are truly beneficial and stop paying for things that are of such marginal benefit that they are nowhere close to worth the money.
And I don’t think most people don’t realize how Medicare decides what it’s going to pay for. The criteria are quality of life and quantity of life. Medicare is not permitted, by statute, to consider cost effectiveness.
So, a procedure, for example, a left ventricular assist device, which Medicare pays for … that’s a machine that pumps your heart for you … has been shown in randomized control trials to lengthen life and improve its quality at a cost of roughly half a million dollars per patient.
Now, if as a society we had to vote between making sure that every person with that kind of heart failure had access to a half a million-dollar procedure and who would want it, and it’s a very small number … versus making sure that every child had health insurance … how would we vote?
But we don’t weigh those things in our society. We just live with the fact that 50 million people have no health insurance and that Medicare will pay for a left ventricular assist device. It’s not rational. And if, if you were someone who was looking at our society from the outside and about to come in as a citizen … what kind of society would you structure? Not knowing whether you’d be rich or poor, sick or well, a baby or an old person. It wouldn’t be the system we have now.
HEFFNER: If you were to ask that same question about the first time citizen and the first time participant in British life, French life, German life …
HEFFNER: What would the conclusion be?
MEIER: Having not lived in any of those societies myself I can’t say whether in some the up-sides and the down-sides of a single payor system would be more likely to be chosen by a, a person who says, “Well, I think I’m going to go live in England instead of America because of the way the health care system is built.”
But if I were an elderly person who needed hip surgery I’d come to America. If I were being born into a poor family, I would go to Britain. And you know, these are political realities that are going to require very sophisticated effective consistent leadership in order to see the shifts that are needed and how health care is paid for.
HEFFNER: If you were to think about your own patient population, do you see the kind of realism that you are demanding of our leaders?
MEIER: Among some. I mean I think each person quite naturally and understandably is there own best advocate. Most of my patients, I have many patients in their nineties and some who are in their hundreds, who are … because they are that old … they are the genetically superior among us. They’re actually remarkably healthy. And make very little use of health care resources. The ones who live that long are just genetically blessed. And it isn’t because of anything we do. And frankly the less we do the better they do.
And there’s actually lots of data out there now that shows that more is less … more medical intervention actually leads to increased complications and mortality in many situations. Medicare data has shown that; that the opposite of what you would think, you would think more medical care is good, better outcomes.
In fact if you look at Medicare patients and their last six months of life, the more interventions, the more doctors they see, the more time they spend in the hospital … the higher their risk of death.
HEFFNER: Well, everybody knows going to the hospital is bad for your health.
MEIER: It’s absolutely true. Not an exaggeration.
HEFFNER: What about hospice?
HEFFNER: Where does that fit in to your …
MEIER: Hospice is a Medicare benefit in this country, it’s essentially free to you, if you have Medicare that enables patients with a serious illness, one that is likely to lead to their death within six months … to receive highly sophisticated care in their own home. No other insurance provides that kind of support and safety net to patients and families with serious illness at home.
And in fact no where else in the world is there as good a health care benefit for palliative care at home, as the Medicare hospice benefit that we have in this country. And we really ought to be grateful for it because we’re very lucky to have it.
There are two eligibility criteria for hospice, one is that your physician has to literally sign a piece of paper saying that you are likely to die within the next six months …
HEFFNER: That’s still true then.
MEIER: It is still true and it’s a huge barrier to getting patients into hospice because it’s very hard to predict who’s going to die in six months. And in fact, most of the time we can’t.
And because we cannot predict … we can predict within a few weeks who’s likely to die soon, but when you get into six months … people defy statistics. Each person is a truth unto themselves. And because of that require …
HEFFNER: What’s the second qualification?
MEIER: … the second qualification is that the patient him or herself has to sign a piece of paper saying that they agree to give up regular Medicare coverage in return for the hospice Medicare coverage. And the problem there is that very few people are willing to give up curative efforts.
MEIER: And I think that’s pretty understandable. In return for this wonderful service at home … nurses, social workers … volunteers, home health aides, free prescription drugs, free equipment, lots of time and care spent with patients and families … so the fact is though what many people don’t know is that you can actually go back and forth.
HEFFNER: But how so?
MEIER: Between the hospice benefit and regular Medicare. So if you have a physician that sophisticated about the health care system, and here’s another place where doctors really need training on how to help their patients work the system … but I have patients who have gone back and forth repeatedly between hospice … so they get the right care at home … and regular Medicare so that they could get the procedures or the surgery or the treatment they needed in the hospital. There is no law against doing that. So if you’re savvy you can get what you need from the health care system.
HEFFNER: But that’s a hell of a comment. Don’t you think, seriously … “if you’re savvy” …
MEIER: Yes. Yeah. Unfortunately, it’s a fact. And I’m saying this because I think people forewarned are forearmed … “forearmed” is what I’m trying to say …
HEFFNER: “Forearmed” … right (laughter)
MEIER: And their children, the children of older people. If they learn about the system and how to work it, can get much better care for the people they care about than if they just kind of assume that everything works well. I’m here to tell you that unfortunately it does not.
HEFFNER: Can we afford the hospice.
MEIER: The data is contradictory on hospice. In certain patient populations hospice saves quite a bit of money. Typically the patient population with advanced metastatic cancer, cancer involving other organs, liver, lung, brain … cancer involving bones. In that patient population care at home is both more effective, in terms of improving quality of life and quite a bit cheaper.
HEFFNER: Because you’ve cut out the curative?
MEIER: Because people are at home instead of in the hospital … basically. The hospital is where the real cost of health care sits and it’s not beneficial to people with advanced Stage Four malignancies … it doesn’t help to be in the hospital. But it’s very, very expensive.
HEFFNER: Is that because of all the technology that is employed then in the hospital?
MEIER: It depends. The way hospitals are paid under Medicare is through something called a DRG reimbursement method. The hospital … if you came in with pneumonia … as a Medicare patient … and were in the hospital for three days for treatment of pneumonia … the hospital will be paid a lump sum payment for your stay in the hospital, regardless of what was done during that stay. Regardless of whether you were treated with penicillin, which is pennies per dose or Zosan, which is hundreds of dollars per dose. The reimbursement to the hospital would be the same.
But let’s say you didn’t stay for three days with your pneumonia. Let’s say you had a complication and went into renal failure. And developed some other infections. And instead this … what should have been a short stay for pneumonia turned into a 50 day stay. The hospital gets paid exactly the same amount. If you were there 50 days or 3 days. And so you can see why hospitals are really worried about going under.
Because increasingly very, frail, complex, multiple illness older people come in with what should be a routine procedure or a routine treatment and end up staying a very long time. And the hospital is not reimbursed for everything that happens over that long time.
HEFFNER: Dr. Meier at the end of our last program, I said you had to come back. This is the end of this program and I say, “You have to come back”.
HEFFNER: Are you willing … in yes or no terms … to talk about physician aided suicide?
MEIER: Absolutely. I’d be happy to talk about it.
HEFFNER: Next program. Thank you Dr. Meier.
MEIER: Thank you.
HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a 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.