Thursday, December 31, 2009

On Reflection at the Turn of the Year: 1

The end of the year is a time for remembering and reflecting.  Several things are on my mind these days.

This year I will be hitting several “30’s:” aspects of my professional life that in 2010 I’ll have been about for thirty years.  There are a number of ways in which I know that, but one of them is literally in my hands.

I don’t mean that this theme in my work is simply in my control.  I mean that I can see the evidence in the skin on my fingers.  My skin is always dry, and frequently cracked.

The issue is hand washing, but the point is not hand washing itself.  I don’t want to suggest that thirty years ago we weren’t concerned about washing our hands, or about a safe, sanitary environment.  Still, some things have changed.  We have always had gloves around, and we’ve always used them for sterile environment.  We’ve always washed our hands, but now every room, and almost every wall in the hospital has one variety of sanitizer or other.

We know, of course, what stimulated that change: AIDS.  AIDS has been with us thirty years, too, or almost.  I remember the early days, when we first heard about “the Haitian disease,” and then about GRID.  Point by point we learned more about this disease.  Those who cared for the sick learned about one opportunistic disease after another.

Eventually, we learned about the virus, HIV.  However, all along we have been washing our hands.  We found by experience that it worked; that is, that health care workers who followed good procedures, including washing their hands and wearing gloves, didn’t get sick.

Not everyone got that message, even once the virus had been identified.  I remember attending the death of a young man from Kaposi’s sarcoma.  A good nurse almost lost her wits when I laid my hands on the young man’s head to pray.

Again, it wasn’t that we weren’t washing our hands before, or wearing gloves in circumstances we thought to need a sterile field.  However, we were making assumptions, and based on those assumptions were washing our hands less, and especially using gloves, less.

We were also washing them out of the sight of the patient.  While much of the time that was because the sinks were simply fewer and farther between, sometimes we did it intentionally.  We did it intentionally with AIDS patients.  Some AIDS patients, already suffering stigma related to their disease or hiding their disease to avoid it, felt that washing hands in their presence suggested that they were somehow “dirty.”  So, to avoid adding to the stigma, or making more uncomfortable patients who were anxious enough already, we didn’t wash our hands in front of them.  We certainly washed our hands, both before and after seeing the patient.  We just did it out in the hall.

We also began to speak of such precautions as being really appropriate all the time.  We began to speak of “universal precautions,” appropriate for all conditions and not simply for AIDS.  Precautions weren’t a comment on the patient, but an effort to keep all patients and all caregivers safe.

In the intervening years that provision has been shown to be wise.  A range of other conditions – resurgent TB, and its drug resistant forms; SARS; Bird Flu; and most recently Swine Flu – demonstrated the propriety of having precautions that were truly universal.  In the meantime, with new medications and better knowledge we discovered AIDS was a disease one could live with, not simply die of.  So, in thirty years even our language has changed.  We now speak not of “universal” precautions but of “standard” precautions; and good hand washing has been complemented with hand sanitizers in various forms in hospitals and homes and virtually everywhere.

And so my hands are always chapped and dry, but my patients and my colleagues and I are safer.  I’m conscious of that a certain prejudice contributes to that: I could use hand cream, but I was raised with the sense that rough hands were a sign that someone actually worked for a living.  I also wonder sometimes whether extending standard precautions from hospital and kitchen to everywhere won’t have other less favorable consequences (Hygiene Hypothesis, anyone?  I wonder….).  But I wash my hands, and rub on the alcohol foam and gel.  And I’m conscious of the changes I’ve seen in my work in thirty years – changes I can literally see in my hands.

Tuesday, December 29, 2009

One Story of a Market Oriented Approach to Health Care

I know that I’ve been quiet here, what with the holidays and all. That doesn’t mean, though, that I haven’t been paying attention. In the midst of all the holiday stuff there have been continued to be some good reporting on health care in the United States. While most of that has centered on the Senate’s bill, and now prospects for reconciliation of the House and Senate Bills in conference, there have still been some valuable stories on the provision of health care.

Like this one from NPR’s All Things Considered. Titled "How A Bone Disease Grew To Fit The Prescription," it’s worth your time (you can read or listen here). It describes how a drug company virtually created a market for a new drug. It’s not that there wasn’t a market at the beginning, but it was small and not very profitable. This is the story of how the drug company moved to create a market, with results we see in television ads virtually every day.

In the process, a number of things happened that are typical of how health care works in a "market approach." The company supported research – but primarily research that supported the need for drugs like the one they were marketing. It worked with doctors, but especially to induce them to prescribe radiology studies that weren’t necessarily all that valuable (and perhaps not worth the incremental radiological risk). It lobbied Congress, so that eventually Medicare and other insurers would pay for all of this. Note that in all of this the company did nothing illegal. As to whether it was unethical – well, that’s another question.

I have said before that part of the problem of our health "system" is a view that health care is a retail item, rather than a public service. That’s where a "market approach" to health care continues to take us, until we make some other provision. This story provides a good object lesson why simply "trusting the market" would likely continue to expand our costs and our exposure to care we just might not need. So, take a few minutes for the story.

Thursday, December 24, 2009

Merry Christmas to All

It has happened once again:

Once in royal Davids city,
Stood a lowly cattle shed,
Where a mother laid her Baby,
In a manger for His bed:
Mary was that mother mild,
Jesus Christ, her little Child.

He came down to earth from heaven,
Who is God and Lord of all,
And His shelter was a stable,
And His cradle was a stall:
With the poor, and mean, and lowly,
Lived on earth our Saviour holy.

For He is our childhood's pattern;
Day by day, like us, He grew;
He was little, weak, and helpless,
Tears and smiles, like us He knew;
And He cares when we are sad,
And he shares when we are glad.

And our eyes at last shall see Him,
Through His own redeeming love;
For that Child so dear and gentle,
Is our Lord in heaven above:
And He leads His children on,
To the place where He is gone.

Wednesday, December 23, 2009

As Advent Ends

It has been, this year, an – well, let’s say odd – an odd Advent. Something has been not quite right.

It has been different this year. After some years away from it, my Best Beloved is working in nursing again. That has changed our schedules – hers because of her work schedule, and mine because it’s rearranged how we divide up household responsibilities; and mine, too, simply because on many days my schedule is more flexible.

Veni, veni Emmanuel;
Captivum solve Israel,
Qui gemit in exilio,
Privatus Dei Filio.

Gaude! Gaude! Emmanuel,
Nascetur pro te, Israel!

It’s been busier, and so things haven’t happened at their accustomed pace. Our Christmas tree did not get brought in until 4th Advent. Now, once upon a time that was because of my insistence that really appreciating Advent required holding of on symbols of Christmas, including the tree. (One year we waited until 4th Advent to put it up, and until Candlemas to take it down. Boy, did we vacuum needles that year!) This year it was simply because when we weren’t too busy, we were too tired.

Gifts are purchase, and, blessedly, family members have made that easier. My sons have made me proud, asking for contributions to charity in their names rather than gifts. They’re certainly right that they don’t really need things, and that others do; but others in similar circumstances still have their lists of toys, adjusted for age and income. So, I appreciate them. Still, if it hadn’t been simpler I don’t know quite when or how I’d have done what I wanted to do.

Come, O come, Emmanuel,
and ransom captive Israel,
that morns in lonely exile here
until the Son of God appear.

Rejoice! Rejoice!
Emmanuel shall come to thee, O Israel!

But what I have noticed most is something smaller, more intimate. I haven’t been singing. I have written at other times of the importance of music, both to console a mood and to create one. In years past as I walked the halls of the hospital I would sing, softly but clearly. I sang for me, primarily, although not so softly that others couldn’t hear. I sang hymns, primarily, and carols for the season. And this year as I’ve run from place to place, I don’t recall singing.

Veni, veni Emmanuel;
Captivum solve Israel,
Qui gemit in exilio,
Privatus Dei Filio.

Gaude! Gaude! Emmanuel,
Nascetur pro te, Israel!

It has been better this week. There is something about the lessons for 4th Advent that turn the corner in my mood, as they are intended to turn the corner in our observance. I preached yesterday on the Visitation, and how it was in many ways our response to Thomas the Forensic (not “Doubting” so much as “Proving”). The concreteness of the kick of an unborn child is in itself confirmation of hope – a confirmation so intimate and so real, even for those of us in the half of humankind who can only feel it from the outside.

And there is today. There are still some 40 hours or so of Advent. There is still some time to hope and to sing and to prepare.

Come, O come, Emmanuel,
and ransom captive Israel,
that morns in lonely exile here
until the Son of God appear.

Rejoice! Rejoice!
Emmanuel shall come to thee, O Israel!

Watch. Wait. Hope; for the day of the Kingdom is at hand.

Friday, December 18, 2009

The Covenant Cometh

The Anglican Communion Office has released today the final draft of An Anglican Covenant, the one that we have awaited for some time. Section Four continues to be part of it. There is need for a more analytical comment, but now that it’s out I have my own thoughts about next steps. Let me say that these are things I hope for, however faint that hope might seem, and not a plan I might propose.

First, I hope that the Episcopal Church as institution will make no immediate comment except to note the release and express interest. (Sure, a great many of us as individuals will comment with heat and at length. I’m talking about the institution here.)

Second, I hope that we will indeed study this carefully between now and General Convention in 2012. However we might feel about it at this point (and, no, I don’t care for Section Four either), out of respect for other national and provincial churches in the Communion, many of whom want to maintain communion with us and might also be interested in the Covenant, we need to take the time and make the effort. (Based on past history, I think we’re more likely to actually study it than many.) This should include exploring whether in fact we could theoretically sign on without affecting our Constitution and Canons.

Third, I hope we will bring this to the 2012 Convention. Specifically, I hope we will bring it piecemeal: that is, I think we should consider in separate resolutions the Introduction and Preamble, Sections One, Two, Three, and Four, and the Declaration. Frankly, I don’t think Section Four would have passed in this past Convention in Anaheim, and I don’t expect it will pass in Indianapolis, either. However, I see no harm and significant good in affirming each section that we can, even if we cannot affirm the Covenant as a whole and sign on.

It’s out. We can read what Canterbury wants us all to agree on. I hope our official responses will be measured and careful. In the meantime, let the shouting begin.

Wednesday, December 16, 2009

Some Reporters Just Make You Wonder (or Just Sigh)

Well, I said in my last post that I wanted to see the article on cholesterol and women, and now I’ve been able to. Well, sort of: I haven’t been able to access the article itself, but I have been able to read the abstract. Having done so, I’m left with one conclusion, one that I’ve expressed before: I continue to be appalled at how the public press picks up on research.

Here is the citation: Matthews, Karen A., Crawford, Sybil L., Chae, Claudia U., Everson-Rose, Susan A., Sowers, Mary Fran, Sternfeld, Barbara, Sutton-Tyrrell, Kim: “Are Changes in Cardiovascular Disease Risk Factors in Midlife Women Due to Chronological Aging or to the Menopausal Transition?” J Am Coll Cardiol 2009 54: 2366-2373 (Abstract here). The research actually was part of a study on women’s health. This is the critical paragraph of the abstract:

Methods: SWAN (Study of Women's Health Across the Nation) is a prospective study of the menopausal transition in 3,302 minority (African American, Hispanic, Japanese, or Chinese) and Caucasian women. After 10 annual examinations, 1,054 women had achieved an FMP [final menstrual period] not due to surgery and without hormone therapy use before FMP. Measured CHD [coronary heart disease] risk factors included lipids and lipoproteins, glucose, insulin, blood pressure, fibrinogen, and C-reactive protein. We assessed which of 2 models provided a better fit with the observed risk factor changes over time in relation to the FMP: a linear model, consistent with chronological aging, or a piecewise linear model, consistent with ovarian aging. (emphasis mine)
So, the point of the study was to determine which would be more predictive, and therefore more useful: whether the woman had entered menopause, or her age. Note that all the women who had experienced menopause had done so “not due to surgery;” nor had they delayed the experience of menopause with hormone therapy. So, these were women who experienced menopause specifically in their natural course.

In fact they determined that for several measures of cholesterol, menopause was more predictive than age, while for other risk factors age was more predictive. However, in neither case was there any implication that menopause wasn’t “natural;” only that in the natural course of things different women experienced it at different ages.

So, the bizarreness of the article (picked up apparently uncritically by was a misreading of the journalists instead of a misstatement by the scientists. That’s not a surprise to me, but it highlights the continuing issue: good research gets misreported in the public press in a way that doesn’t serve the public.

Sunday, December 13, 2009

Some Stories Just Make You Wonder

My Best Beloved brought this to my attention.

CNN picked up this story from “Cholesterol jumps with menopause, study shows.”  It begins thus:

Doctors have known for years that a woman's risk of developing heart disease rises after menopause, but they weren't exactly sure why. It wasn't clear whether the increased risk is due to the hormonal changes associated with menopause, to aging itself, or to some combination of the two.

Now, we have at least part of the answer: A new study shows beyond a doubt that menopause, not the natural aging process, is responsible for a sharp increase in cholesterol levels.

This seems to be true of all women, regardless of ethnicity, according to the study, which will be published in next week's Journal of the American College of Cardiology.

My best beloved read this and came to find me, laughing.  Let’s take a look at that second sentence:

Now, we have at least part of the answer: A new study shows beyond a doubt that menopause, not the natural aging process, is responsible for a sharp increase in cholesterol levels.

So, just when, we asked one another, did menopause cease to be part of the natural aging process for all women?  And if we needed any reaffirmation of that question, the next sentence is, “This seems to be true of all women, regardless of ethnicity, according to the study,…”

I have to tell you, I just can’t wait to get a look at this study….

Friday, December 11, 2009

At Episcopal Cafe: Another Difficult Question

My newest post is up at the Episcopal Cafe.  It's another of the hardest questions, but one that I think we as Christians have to face, and especially as we consider how to provide health care for all.

My friend and colleague Rosemary Flanigan of the Center for Practical Bioethics says that ,"there is no objective “harm” or “benefit” in utilitarianism."  Well, perhaps that's true in the abstract.  I would suggest, however, that when we get to application, and especially when we as a body politic get to application, issues of "harm" or "benefit" become very personal; and so do the decisions.

Tuesday, December 08, 2009

Flashing Lights Across the Sky

We have received today the communiqué released at the end of the meeting of the Inter-Anglican Standing Commission on Unity, Faith and Order (IASCUFO). They have completed today a meeting that began on December 1. The release is certainly timely. Yet somehow I wonder if it isn’t already too late.

The communiqué recalls the origins of the Commission:

The Commission has been established by the Lambeth Conference, the Primates’ Meeting, and the Anglican Consultative Council. It builds on previous work done by the Inter-Anglican Theological and Doctrinal Commission, the Inter-Anglican Standing Commission on Ecumenical Relations, and the Windsor Continuation Group. It reports to the Standing Committee of the Anglican Communion.
Now, like many, this origin story is a bit expanded. The Commission was approved at Canterbury’s request by the Joint Standing Committee of the Anglican Consultative Council and the Primates’ Meeting. While one could argue that that suggests representation by all the Instruments of Communion, it really bypasses full representation (and when did we start calling the Joint Standing Committee “the Standing Committee of the Anglican Communion?”).

Over all, the communiqué is largely a report saying, “We met.” This was a first meeting, and the most important activities were matters of getting to know one another and to learn about one another’s contexts. They met, of course, with the Archbishop of Canterbury, and shared with one another in Eucharist. Beyond that (and as meaningful as those activities were), they didn’t do a lot of work in this meeting.
The Commission had a daunting enough task at its inception:

Mandate of the Inter-Anglican Standing Commission on Unity, Faith and Order
The Standing Commission shall have responsibility:
• to promote the deepening of Communion between the Churches of the Anglican Communion, and between those Churches and the other Churches and traditions of the Christian oikumene

• to advise the Provinces and the Instruments of Communion on all questions of ecumenical engagement, proposals for national, regional or international ecumenical agreement or schemes of co-operation and unity, as well as on questions touching Anglican Faith and Order

• to review developments in the areas of faith, order or unity in the Anglican Communion and among ecumenical partners, and to give advice to the Churches of the Anglican Communion or to the Instruments of Communion upon them, with the intention to promote common understanding, consistency, and convergence both in Anglican Communion affairs, and in ecumenical engagement

• to assist any Province with the assessment of new proposals in the areas of Unity, Faith and Order as requested.

However, in this meeting it found some additional issues requiring “immediate” attention:

1. to undertake a reflection on the Instruments of Communion and relationships among them;

2. to make a study of the definition and recognition of 'Anglican Churches' and develop guidelines for bishops in the Communion;

3. to provide supporting material to assist in promoting the Anglican Covenant;

4. to draft proposals for guided processes of ‘reception’ (how developments and agreements are evaluated, and how appropriate insights are brought into the life of the churches);

5. to consider the question of ‘transitivity’ (how ecumenical agreements in one region or Province may apply in others).

These tasks, which will be taken forward by working groups consulting electronically between meetings, aim to strengthen the unity, faith and order of the Communion.
Unfortunately, even an immediate response may not be fast enough. Things are changing that will, I fear, overtake the work of the Commission. The Commission itself made note of the election in Los Angeles of two bishops suffragan, one of whom is a partnered lesbian woman. The communiqué echoed Canterbury’s response to the election with a request for “gracious restraint” (and I would be very interested in comments on that statement from the Commission members from the Episcopal Church, as well as from Southern Africa and Aotearoa/New Zealand/Polynesia). Should the election of Bishop-elect Glasspool be confirmed (and I think it will; and for full disclosure I think it should), how will Canterbury respond?

Remember, too, that his response will have consequences. If he condemns the Episcopal Church outright (not something he’s been inclined to do so far), there will be reverberations in Canada, Aotearoa/New Zealand/Polynesia, Scotland, Wales, and elsewhere. Should he fail to condemn the Episcopal Church sufficiently, there will be reverberations in Nigeria, Kenya, Uganda, Southern Cone, and elsewhere. If, as he has in the past, he tries to follow a fine line, parsing a statement that is precise but measured, there will be reverberations in all directions. Even in the face of an outright condemnation, I don’t think the Episcopal Church will declare communion with Canterbury broken; but for lack of sufficient condemnation some provinces might.

As a consequence, the Anglican Covenant will be largely pointless. There may still be an effort, but there will likely be too few national and provincial churches willing to sign on for the Covenant to be meaningful. This will become more true the longer “constitutional processes” take for national churches and provinces to even decide whether to sign on or not.

They may still have time for a study of definition and recognition of “Anglican Churches,” if they hurry. However, discussion of anything with as long a horizon as “reception” may well be moot (if that weren’t going to be moot anyway due to the Covenant process).

The communiqué of the Inter-Anglican Standing Commission on Unity, Faith and Order has a hopeful tone about it, even with its paragraph on the election in Los Angeles. Still, for important parts of the Commission’s mandate it may well be too late already. With circumstances changing so rapidly, this “UFO” may well be as elusive as any seen in the night sky.

Sunday, December 06, 2009

Reflection on the Gospel for 2nd Advent, Year C

“In the fifteenth year of the reign of Emperor Tiberius, when Pontius Pilate was governor of Judea, and Herod was ruler of Galilee, and his brother Philip ruler of the region of Ituraea and Trachonitis, and Lysanias ruler of Abilene, during the high priesthood of Annas and Caiaphas, the word of God came to John son of Zechariah in the wilderness.” (Luke 3:1-2)

When I read these verses in preparing to preach, they sounded so very familiar.  Now, in part that was because Luke does this a number of times.  He begins his gospel speaking about Zechariah, John’s father, and notes that events happened when Herod was King in Judea.  More famous is the beginning of his story of the Nativity, when he notes that Augustus was Emperor, and Quirinius Governor of Syria.  This is clearly something Luke just does.

But, I felt there was more to it than that.  This was familiar behavior on Luke’s part, but it also seemed significant for some other reason.  And then it hit me: this was familiar to me because it was evidence that Luke was a physician.  Luke was dating his entries!

Friday, December 04, 2009

Not Gone; Just Doing Other Things

No, I haven't disappeared or lost interest.  I took the whole week off for Thanksgiving, and more; and the short week that I've been back at work has been interesting, to say the least.  However, I'm still here, and there's new stuff on its way.

So, I just finished The Necessary Beggar, a novel by Susan Palwick.  Susan volunteers in chaplaincy, and sometimes writes about her experience at her blog, Rickety Contrivances of Doing Good (which is why I always have her linked to your left).  There's more to know about her, but that's just more reason to link over.

Beggar is science fiction/fantasy, but gives a very interesting take on issues of compassion, love, and faith.  From a clinical perspective, it has a powerful theme of the consequences of shame and secrets in families.  It also portrays the experiences of refugees well, and how folks from other cultures encounter one another (really analogous to the familiar "man from Mars" thought experiment).

So, take a look at Susan's blog, and look into her books.

Friday, November 20, 2009

Thoughts from a Colleague

A good friend of mine has posted something on his own blog about an experience unique to - and really uncommon in - chaplaincy: being present when organs are recovered for donation.  Take a look.

New Words at Episcopal Cafe

I love good, reflective word play.  (For that matter, I like not-so-good word play, too.  I generally appreciate a pun in proportion to the pain it inflicts.)  So, my newest piece at the Cafe involves reflections on some words we sometimes use interchangeably - but, I don't think they really mean the same thing.

While you're there, take some time to read what others have written, too.  And if you have a response to make, please leave a comment.  That process has gotten easier, I hope.  TypeKey has changed their process, and now folks can log in using logins and passwords they already use for Google, Yahoo, etc.  So, take a look and leave a note.

Wednesday, November 18, 2009

This Week's Lesson in Comparative Effectiveness

Before I came to my current hospital and health system, I served in a large tertiary referral hospital. My areas of responsibility included several intensive care units. In those units physicians were working with the APACHE System. APACHE stood for “Acute Physiology, Age, Chronic Health Evaluation.” APACHE was a means of predicting outcomes for patients admitted to intensive care units. It went through several generations (some institutions are still using APACHE III), but all were based on the same process. Information about thousands of patients was recorded over time, including their conditions at admission to the ICU and the outcomes of their stay. The point was to use that information to project the outcomes of future patients based on similar conditions at admission.

This was explained to me by a medical resident. He could put in the characteristics of a given patient, and have the computer to compare them with past patients. Based on the results with those past patients, the computer would come out with a set of ratios. For example, they would look at Patient A and put in his circumstances. The computer would then give some percentages – say, of those historical patients with these circumstances, 70% died and 30% lived to leave the ICU.

As I reflected on APACHE and discussed it with physicians, I realized two things. First, it could offer some guidelines that could be helpful. If the statistics were, say, 90% and 10%, the prediction could be pretty clear. However, it also still required a physician, for all the automation. It still required a physician to look at this specific patient – say, Patient A – and make the professional assessment as to whether Patient A more likely fell into the 90% or the 10%.

That came to mind again with the announcement that the U.S. Preventive Services Task Force (USPSTF) had published new guidelines for mammography and breast self examination. The new guidelines were significant change. Indeed, they were so significant that the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG) have publically disagreed, saying they will continue to follow earlier recommendations.

Most folks are aware of the changes from extensive news coverage (I would suggest looking here or here.) What I think makes this interesting is that it coincides with discussions about health care reform, and highlights one of the important issues in that discussion. You see, this is a straightforward example of the promise and the difficulties of comparing effectiveness of procedures in evidence-based medicine.

Comparing effectiveness is how we got to these recommendations. USPSTF is an independent panel of functioning under the auspices of the Department of Health and Human Services (HHS, and specifically under the Agency for Healthcare Research and Quality [AHRQ]). The panel is independent in that none of its members are employed by the federal Government, nor do they represent agencies within the Government. The purpose of USPSTF is “to evaluate the effectiveness of clinical preventive services that were not previously examined; to re-evaluate those that were examined and for which there is new scientific evidence, new technologies that merit consideration, or other reasons to revisit the published recommendations;…” They want to bring the best science to considering and reconsidering those steps we take to prevent illness and reduce its severity.

Of course, changes in science should bring new consideration and so new recommendations. On the other hand, we’re seeing clearly how those new recommendations themselves can bring their own questions. ACS and ACOG and many women are asking about these new recommendations, “What are the risks that disease (and for the women involved, “my disease”) will be missed with fewer screenings and a downplaying of breast self-exams?” And there is certainly some risk that some patients’ lumps will be missed. Actually, there’s near certainty that there will be women whose lumps will be missed and who will suffer as a consequence.

At the same time, the new recommendations are based on some other certain risks. False positives do result in unnecessary procedures, from additional radiological studies to additional biopsies to unnecessary surgeries; and each of those additional procedures has its own inherent risks. An additional x-ray is a radiation exposure. Unnecessary surgeries include the risks of infection and other complications, both from the surgery itself and from the required anesthesia. And that’s without the impact on the lives of women of additional anxiety and disruption of their lives and relationships, all based on false information. Unfortunately, with the current recommendations these unnecessary risks are happening.

Both sets of risks are measurable, at least across populations. That is, looking at medical practice as a whole, these experts can make good estimates of what those risks are.

According to the newly published research analysis:
  • 1,904 women between the ages of 39 and 49 would need to be invited for screening to have one breast cancer death prevented.
  • 1,339 women between the ages of 50 and 59 would need to be invited for screening to prevent one death.
  • 377 women between the ages of 60 and 69 would need to be invited for screening to prevent one death.
On the other hand, “about 60% more false-positive results could be expected for every 1,000 mammograms performed when screening is started at age 40 instead of 50.”

So, why all the attention and the anxiety? The numbers make it look straightforward to change practice – unless you’re a woman already anxious, or at least alert and attentive, about your individual risk of breast cancer. Why should 1900 women suffer unnecessarily to prevent the death of the 1901st? It’s a good question, but doesn’t address the difficulty that we can’t know who which woman in those 1901 will actually be the one whose death is prevented.

Now, a part of the answer is the same in this case as in APACHE: it’s up to physicians to speak with their patients and say, “In your case, with your personal and family history and your risk factors, this is what I recommend.” However, there are other potential complications. Most insurers, from Medicare to the smallest commercial insurer, reimburse doctors for procedures and not for conversations. Will the doctor, however well intentioned, feel she or he has the time? Most insurers, from Medicare to the smallest commercial insurer, want to avoid paying for “unnecessary” procedures. Will they be willing to make exceptions? And how much effort will it take from patient and doctor for exceptions to be accepted?

This will be an ongoing issue if our standards for guiding practice are based on evidence of comparative effectiveness. We will continue to struggle to balance good general practice with good practice in specific cases. We will continue to wrestle with how to make the important exceptions to the structures we put in place to spare risks and costs for the majority of patients; for those important exceptions are people first and foremost.

I’m still a great believer in “comparative effectiveness.” I think it will be an important step in “bending the cost curve” in health care – which is just a fancy way of saying that we want to slow the pace at which costs for health care go up. At the same time, we need to be aware that to change based on “comparative effectiveness” will not be easy. It will take more work, and not less. It will involve especially more hard thinking by doctors and professionals, and more hard conversations between professionals and patients. “Comparative effectiveness” will come with its own difficulties; and the current discussion about recommendations for breast cancer screening are giving us a good example.

Monday, November 16, 2009

A Nice Moment

So, today at a meeting of hospital leadership the CFO spoke about a new software package the health system had purchased.  The reason to buy the software was to simplify the process of recording time spent on activities for “community benefit.”  We keep track of those activities because we want to demonstrate each year that our tax-exempt status is appropriate.  After all, the justification for exempting certain organizations from taxes is that they provide benefit to the community equivalent to the benefits that taxes would otherwise pay for.

The CFO said, “All the managers who need to be trained in this software have received email telling them to attend training.”  But, I hadn’t received any email.  And I do a lot in the community, both in churches and elsewhere.

So, after the meeting I stopped the CFO, and said, “I didn’t get the email.  Certainly, I need the training.”

The CFO answered, “No, you don’t.  We consider all of your work to be of community benefit.  You don’t need to keep track of your community benefit hours, because we’ll simply count all your hours.”

It’s nice to be appreciated!

Tuesday, November 10, 2009

What's In It for the Romans

Well, there’s a great deal of conversation (and a certain amount of consternation) about the Apostolic Constitution  Anglicanorum Coetibus.  If it hasn’t come to your attention, you can find some good commentary at Thinking Anglicans

This Apostolic Constitution has been prepared after years of requests and discussions with the Traditional Anglican Communion, a community whose founders left churches in the Anglican Communion beginning a generation ago over the ordination of women.  At the same time, it arrives in an interesting context.  First, there are other groups of former Anglicans, who have left churches in the Anglican Communion over issues of sexuality.  Second, the Church of England, long the center of the Vatican’s (arguably myopic) perspective of things Anglican, has committed to the ordination of women to the episcopate and has begun to figure out just how to locally adapt that for their circumstances.  As a result, while the folks of TAC are ready, waiting, and basically committed, there are also others both in and outside churches of the Anglican Communion who might be interested.  Certainly, folks in Forward in Faith have certainly expressed some interest; while others, with a more evangelical perspective, have said, “No thanks.”

I have read both the document itself and the Complementary Norms.  Others have noted what this means for the orders and structures of the Personal Ordinariates for the former Anglicans.  However, what struck me about these documents had to do with relations with priests of the Ordinariates and the Roman dioceses.

The importance of such a relationship is established in the Apostolic Constitution in Article VI, paragraph 4: “Priests incardinated into an Ordinariate, who constitute the presbyterate of the Ordinariate, are also to cultivate bonds of unity with the presbyterate of the Diocese in which they exercise their ministry. They should promote common pastoral and charitable initiatives and activities, which can be the object of agreements between the Ordinary and the local Diocesan Bishop.” This would be important, of course, because the Personal Ordinariates for former Anglicans will not be territorial in the same sense as Roman dioceses, and so will overlap one or more dioceses.

What this might mean (and why this might be more interesting to Roman bishops) is clarified in Article 8, paragraph 1, of the Complementary Norms, “The presbyters, while constituting the presbyterate of the Ordinariate, are eligible for membership in the Presbyteral Council of the Diocese in which they exercise pastoral care of the faithful of the Ordinariate.”  That is, while they are priests of the (non-territorial) Anglican Ordinariate, they can also be members of the (territorial) Roman diocese within which they live and/or work.  This only makes sense, because in Article 9, paragraph 1, “The clerics incardinated in the Ordinariate should be available to assist the Diocese in which they have a domicile or quasi-domicile, where it is deemed suitable for the pastoral care of the faithful. In such cases they are subject to the Diocesan Bishop in respect to that which pertains to the pastoral charge or office they receive.”  This does require a written agreement between the Roman Bishop and the Ordinary of the Ordinariate; but with that agreement (and how is the Ordinary to refuse the Bishop) the Bishop can call on priests of the Ordinariate to assist in Roman parishes.

Now, that arrangement can work the other way.  However, it’s notable that “clerics incardinated in the Ordinariate should be available to assist the Diocese;” while “clergy incardinated in a Diocese… can collaborate in the pastoral care of the Ordinariate,” but only “[w]here and when it is deemed suitable.” (Emphases mine)

That suggests to me that the real value of this to Roman bishops is as a new source of assisting clergy.  There is a clear priority of Ordinariate clergy serving Diocesan needs.  In the face of the clergy shortage any new source of personnel has to be interesting.  Moreover, they’re inexpensive personnel; for Article 7 of the Complementary Norms makes clear that the Bishops have no financial responsibility for these new clergy: “The Ordinary must ensure that adequate remuneration be provided to the clergy incardinated in the Ordinariate, and must provide for their needs in the event of sickness, disability, and old age.”  There is, of course, provision for Ordinariate clergy to have secular employment if necessary; but in neither case is the Roman bishop on the hook for these expenses.

Now, let me say again that I know this came about the accommodate TAC, and perhaps a few other former Anglicans and Episcopalians (after all, even if they’re not “former” now, they’ll become “former” once they enter the Vatican’s jurisdiction).  At the same time, it can’t have been missed that this will provide Roman bishops with a new resource for clergy, and with clear primacy of Roman bishops over Personal Ordinaries.  I can’t help but wonder if this is the sort of recognition and acceptance that the former Anglicans have in mind.  And I can’t help but wonder if this isn’t what will make this new arrangement acceptable to the Diocesan bishops who will find these folks on their doorsteps.

Monday, November 09, 2009

Where I've Been Lately

I have been on vacation.  Well, to use the trendy term, I’ve been on a “stay-cation,” since my Best Beloved couldn’t get away from her work.  But I reached an important point in the year.  I received a message from my boss who asked, “Do you know how much vacation time you have built up?  Do you know how much of it you use if you don’t lose it before December?”

So, I’ve been on vacation.  Unfortunately, vacation is something I don’t do all that well.  Oh, I can stay home instead of going to the hospital.  I can turn off the alarm and sleep in; which is to say that I can sleep until 7:00 a.m., instead of rolling out by 5:30.

I can set aside some reading.  I went to the library and picked up a couple of books.  Of course, one of them was Sanjay Gupta’s new work on wonderful new medical discoveries.  I set aside some other light reading – articles from the New England Journal and from Resuscitation.

I’m just not good at taking time off, unless I’m really away.  Let me charter a sailboat, or get away to a monastery, and after a little adjustment – okay, two to three days’ adjustment – I can stop thinking about professional things and attend just to what’s around me.  I can leave the phone off, and do nothing more professional than say Morning Prayer and Compline.

Somehow, taking time off at home just isn’t the same.  I know it’s my own fault.  There’s plenty of distraction.  The garage has to be converted back from garden staging area to auto storage.  Hot peppers and raspberries are still coming, if the tomatoes are past it and the basil has shriveled.  Leaves are accumulating on the lawn.  With winds prevailing from the west, no one on my block rakes his own leaves.  Instead each of us rakes up the leaves that blew from the trees of the neighbors to the west.  So, there’s plenty to do.

There are opportunities for cleaning and cleaning out.  It took me a while to work out recycling the old dehumidifier (it was both harder than simpler than I had imagined).  Some of my Styrofoam packing material was clean enough to recycle, but some wasn’t.  Still, my Best Beloved was pleased with the vacuuming.

And I managed not to check my work email – well, not more than once a day.  After all, I didn’t want to get back into the office and have several hundred emails to clear out (and I’m afraid that’s not much of an exaggeration).

But, really, I’m not a workaholic, and I did enjoy my time at home.  I still have some time to work at it.  I still have more vacation days to burn off.  I’ll take some time around Thanksgiving.

Just be patient with me.  I enjoy taking time away.  I’m just not very good at it.

Saturday, November 07, 2009

Carrying our Ministry: the Chaplains at Fort Hood

Pray for all of those who have died and suffered in events at Fort Hood, Texas.  Pray for the repose of the souls of the dead.  Pray for easing of suffering and hope for the wounded.  Pray for strength and comfort for families in shock, mourning, and fear.  Pray for health care providers, both those who were serving in the midst of the attack, and those who afterward served the injured and suffering.  Pray for the alleged shooter, that God may touch his heart and turn it from violence back to the peace which passes understanding, whether in this life or the next.

And pray for the chaplains who serve them all.  Several years ago I expressed my admiration and appreciation for my colleagues who serve in the Armed Forces.  Today at the Cafe there are the reports of those serving now at Fort Hood.  I often speak of how honored I am as a hospital chaplain to carry the ministry of the Episcopal Church to so many bedsides.  Today I am honored to be a colleague to the chaplains at Fort Hood, as well as the clergy of Killeen, who are carrying that ministry into the midst of death and injury, fear and anger, sadness and hope.

Monday, November 02, 2009

Sometimes It's Hard to Claim Middle Ground

 Published in Spirit, a new quarterly publication of the Diocese of West Missouri:

Some years ago at Clergy Conference I found myself in intense discussion with a colleague from the Southern Deanery.  He was more conservative and I more liberal, but the discussion was really good.  We were discussing how best to provide for the poor.  What made the discussion good had little to do with how.  We didn’t agree on how much at all.  However, we could agree that, however much we disagreed about how, we were called as Christians to be concerned for the poor.  We could disagree respectfully about the means because we could certainly agree about the end.

I was honored when Hugh Welsh invited me to write the first column in “The Middle Ground” in the new Spirit.  His goal for the column, as he shared it with me, was “to find a middle passage (if you will) between a hot topic with a stated pro and con.”  Certainly, there are a number of pros and cons related to universal access to health care.  Whether we speak about “health care reform” or “health insurance reform,” there are certainly different points we might consider. 

We can certainly have respectful arguments about the means.  We can ask just how much Government action is required, and how much we need to focus on personal accountability.  We can think about how to balance employer mandates and individual mandates and subsidies to help the working poor buy insurance.  We can discuss balancing cost control for physicians with tort reform.  We can discuss various means to provide access to health care for all Americans.

However, what we can all agree about as Episcopalians is that providing that access to health care is an appropriate end.  In General Convention we have called on our government to pursue health care reform since at least 1985.  We have reaffirmed it as recently as this summer, when General Convention passed three resolutions on to universal access to health care.

We take that position because it’s consistent with our faith.  It is consistent with the Summary of the Law, that in addition to loving the Lord our God we are called to love neighbor as self.  It is consistent with the Baptismal Covenant; for the Apostle’s teaching calls us to proclaim by word and example, serving Christ in all persons.  So, for us this is the end on which we can agree, even if we see pros and cons about how.

Unfortunately, there are those who do disagree that this is an appropriate end.  They may argue that we lose freedom if the government is involved.  They may argue that an informed individual can make better decisions for his or her own good than any bureaucrat.  However, if we listen carefully we will discover that their arguments come back to a single theme: that I have a right to make the decision that is best for me and mine without regard for anyone else.

That may be legal, but we wouldn’t call it “true,” because it isn’t true to the faith as the Episcopal Church has received it.  We continue to believe we are called to love neighbor as self in ways that proclaim by word and example the good news of God in Christ.  And so we agree that this goal, this service, and specific strategies to achieve it, like universal access to health care, is an end to which God calls us, even if we might disagree about the means.

Wednesday, October 28, 2009

When States Collide

While I haven’t read the book, I’ve been interested and sometimes amused at the title, What’s the Matter With Kansas.  You see, while I live in western Missouri (or as we commonly say, “On the Missouri side”), and my health system is headquartered in Missouri, the hospital I serve is in Kansas.  As a result, I pay attention to health news from Kansas with as much attention as from Missouri.

So, I didn’t miss this news item in my local paper: “Kansas state lawmakers push for health care insurance opt-out.”  It seems that three Kansas legislators have decided that any public option offered as a part of national health care reform would be an unacceptable trampling on states’ rights.  Moreover, they fear it will become a trampling on the rights of citizens (although whether they are more concerned about individual citizens or corporate citizens - i.e., insurance companies - remains to be seen).  To that end, they want to amend the state constitution to say that any health insurance mandate, whether requiring individuals to purchase health insurance or requiring employers to provide it, cannot be enforced in Kansas.

My initial reaction to this was that these state legislators were raising this issue only in Kansas.  In fact I was uninformed.  There have been efforts in other states for months now.  They are coming from conservatives who state they’re placing a high value on freedom to choose, including the freedom to choose not to purchase health insurance.  Thus, Federal individual and employer mandates are unacceptable.  In fact, for some apparently a Federal effort to make health insurance more affordable by offering a public option in a health insurance exchange, thus creating competition for private insurance companies, is somehow coercive.  So in many places efforts are being made to change state constitutions to prevent this perceived Federal encroachment.

Now, I will say first and foremost that, even if these constitutional changes pass in some states, I don’t see how they can stand for the long term.  I have already argued that all health is public.  Indeed, we’ve seen just how public it is in our current H1N1 flu pandemic.  With this, and with any contagious disease, we have reaffirmed that we are our siblings’ keepers, at least in this.  What I do to protect myself from getting the flu also protects anyone I might infect if I get it.  For me hospital patients are the special group for concern; but it also protects the grocery clerk and the waiter and the librarian whom I encounter, and even the grocery customer and the diner and the library patron who cross paths with me.  For much of our health care, we depend on a certain “herd protection.” 

It’s also the case that economically we are our siblings’ keeper.  We all pay for one another’s health care, whether it’s through taxes or insurance premiums or through the price increases brought about by losses for unreimbursed care.  That is already the case, and it won’t be changed by the reforms currently considered in Congress – or for that matter any reforms that weren’t considered.  Nor will it be changed by an attempt to prevent some government management of the competition among insurance companies.

A consequence of both these facts is that health care, and so reimbursement (or lack of reimbursement), is a matter of interstate commerce.  I am acutely aware of this in my position.  As I said, I live in Missouri but work in Kansas.  In fact many people in the eastern counties of Kansas find their health care in institutions in Missouri.  That’s a common enough occurrence in the Kansas City area, of course; but it’s also true farther south, where the larger towns and larger institutions are east of the state line.  While I don’t know the numbers, I can only imagine that in the far western counties folks who need intensive care find it in Denver or Colorado Springs.  I would bet, too, that some in the northeastern counties find it in Omaha or Lincoln.  So, in my part of the world health care is explicitly interstate commerce.

That is a regional expression, but there are other ways.  Think, for example, of the large networks of health care providers.  Such for-profit companies as HCA and Tenet are certainly interstate companies.  So are such religious networks as Adventist and Ascension.  Now, they deal already with differences between states.  However, they might find if difficult to do business in a state if it essentially establishes a population risking unreimbursed care.

One way or another, states that allow individuals to go without insurance, through lack of an individual mandate or of an employer mandate or through some other mechanism, will necessarily place burdens on institutions in other states, and so on citizens in other states.  That seems to me ripe for a decision from the Supreme Court; but that would take years.  It might take years, too, to change state constitutions; but one can only hope that those efforts fail.  Health care issues respect our political divisions no more than the illnesses that raise issues.  Let’s hope that most of our citizens, and the legislators that represent them, will see this clearly and take responsibility, not only for their own individual health needs, but also for the needs of their fellow citizens.

Monday, October 19, 2009

During the Festivities

While I don’t make reference to it here, folks know that the system and the hospital within which I work are named for the Evangelist who was also a physician.  This week in our system is Saint Luke’s Week, when we highlight the work of chaplains in the system.

One of the special events I schedule during Saint Luke’s Week is the Blessing of the Hospital.  Using a service modeled on house blessings, I walk through the hospital praying and asperging with holy water.

Today as I made my way through the hospital, folks noticed smoke coming from the hospital’s roof.  It was a simple mechanical issue with no risk to person or property.  However, we did get an immediate response from the fire department, which simply added to the concerns of observers.

At a later point, one of our administrators stopped me and, smiling, asked whether I thought my blessing was responsible for the smoke.  I said, “Well, I don’t know, but I suppose I might have hit something evil.” 

His eyes widened for a moment; and then he smiled.

Thursday, October 15, 2009

Curious Connection Up at Episcopal Cafe

So, my newest piece is up today at Episcopal Cafe. Just to peak your interest, this is the first sentence: "So, there I was, watching Project Runway, when I found myself thinking about Clinical Pastoral Education." Now, if that doesn't make you curious, I don't know what will.

So, go over and take a look at the Cafe. And while you're there, read what my colleagues have also written - read, and take the time to leave a comment. We're there to show just what good stuff folks in the Episcopal Church have to offer..

Tuesday, October 13, 2009

One Step - and On To the Next

Well, the next step has been taken. The Senate Finance Committee has voted out its health reform bill.

While this has gotten a lot of attention, I don’t really think it the significant step that the media makes it out to be. Certainly, it is interesting in that it managed to get a vote from a Republican senator, after involving three in the process of writing it. However, this is not the final bill, nor even the final Senate bill. There is another bill in the Senate, from the Health, Education, Labor, and Pensions Committee (the HELP Committee – no kidding!). There will be negotiations to blend these two bills, and that will become the Senate bill.

And then there is the House bill – and in fact there are three of those. HR 3200 has gotten a lot of attention, but it will have to be blended with two others to produce the House bill.

And finally there will be a Conference Committee. The bill produced by the Conference Committee and passed in both Houses in the same form will be the bill that gets to the President’s desk (see, I did pay attention to “Schoolhouse Rock”).

So, keep watching, siblings; and keep writing to your senators and representatives. This isn’t over until it’s over (and, really, it won’t be over until we see it implemented). Keep watching.

Wednesday, October 07, 2009

"If your only tool is a hammer...."

We have a new procedure at our hospital – well, new and not new. The principle has been around for – well, anecdotally, almost forever – but we have come to apply it again. It is also new to our setting.

This “new” tool is hypothermia: lowering the body temperature of a patient to slow metabolism. We’ve all heard the stories of the victim who fell through the ice on the pond. After time under water the victim is removed, cold and apparently lifeless. However, a pulse returns, and with time the victim recovers – not only physical function but mental function, too.

This has been done in hospitals in the past, and for varying conditions, but with varying results. Now, protocols have been developed, and in our hospital and many others it has become a new tool in cases of cardiac arrest when there has been some period with no pulse, and so with probability of loss of oxygen to the patient’s brain. The hope is to preserve brain. (You can see information about it here.)

Not long ago, I asked one of our cardiologists about the studies that had been done to demonstrate the value of hypothermia. I specifically asked about the results of those studies. He said that the success rate was about 10%. That is, the number of patients with good outcomes was 10% higher among those treated with hypothermia than among those who were not.

Now, in one sense, a 10% result may or may not be a big deal. If it’s the difference between respective recovery rates of 90% vs 99%, that’s important. If it’s the difference between 10% and 11%, how important is it? If it's the difference between 50% and 55%, how do we decide? And of course the answer to that question must take into account how devastating the disease (and let’s be honest: the neurological consequences of hypoxia caused by cardiac arrest can certainly be devastating), and whether it’s your loved one in the ICU bed.

That raises some corollary issues. The most important is, for which patients do we use this? The studies I’ve been able to find and look at (mostly in abstracts) are small, and address several different presenting diagnoses: cardiac arrest, certainly, but also cardiac arrhythmia, strokes, and neurotrauma. Some were more pilot studies of one sort or another, either to demonstrate enough response to be worth studying, or to look at different mechanisms for cooling and/or warming the patient. An important issue in research ethics is just how much we can generalize from one study to another – from a small study to a large one, from a procedural study to a treatment protocol, from one diagnostic patient group to another. It is also an important issue in moving from a study to a treatment protocol.

There are also issues around the duration of the protocol. You see, to commit to this protocol takes time. The patient must be gradually cooled to the appropriate temperature, maintained at that temperature for an extended period of time, and then gradually rewarmed. The point of the protocol is to protect neurologic functions, but those functions can’t be assessed until the patient has been sufficiently rewarmed. So, we’ve committed the patient and ourselves to two or more days of intensive care before we can really assess progress. If it’s successful, no one questions the value. However, if that 10% is a small margin in a situation of low expectations, one has to ask whether there has been an appropriate use of resources. There are issues of justice if we’re providing this lengthy and expensive protocol (in all resources, but money symbolizes them all) with little expectation of meaningful recovery.

We’ve also committed the family to two or more days of watching and waiting. During that time, there is little we can tell them. After all, the patient has been put on the protocol because of a devastating event. However, while the protocol is in process, we can’t really assess the consequences of the event, nor advise the family on what to expect. We speak often in health care about the difference between extending life and prolonging dying. If we can’t assess, how do we know which we’re doing, and what can we tell the family about that? We don’t want to give false hope – indeed, in my hospital that is explicitly stated in orientation to the protocol – but to engage the protocol at all is to offer hope before we can know whether it’s reasonable or false. I will acknowledge that this is true of all emergency medicine, and much intensive care; but that doesn’t absolve us of addressing this concern.

What this really presses us to do is ask when it’s appropriate to use the protocol. That really is a question of which patient is an appropriate participant: which diagnoses suggest it, and which related factors exclude it. The thing is that the studies don’t really clarify that. Once again, the few studies address a number of different presenting diagnoses, and those differences make a difference. In addition, any study also has exclusion criteria. A good study is looking at a specific, relatively narrow question, and not every patient would help answer that question. So, there are criteria for including a patient in a study group, and criteria for excluding. However, different studies have different exclusion criteria. That also makes the results hard to generalize. Narrow criteria for inclusion and variable criteria for exclusion add to the difficulty deciding which patients might benefit from this protocol for treatment. Can the patient be too young or too old? Are there other physical conditions that might affect the patient’s survival independent of brain injury, such as liver failure or metastatic disease? It’s possible to look online at hypothermia protocols from various institutions, and see that there are differences between their exclusion criteria (for example, here or here). So, once again, have we invested resources in patients who won’t benefit for reasons independent of this event? Have we offered hope to a family in a situation that is medically futile for reasons independent of this event?

So, how is it that we offer this protocol to our patients? The real answer is that the events are indeed as devastating as I’ve suggested. Loss of blood flow and of oxygen to the brain is devastating, whatever the cause. Our colleagues specializing in stroke have for some time encouraged rapid response to stroke symptoms with the phrase, “Time is brain;” and that’s just as true when it’s caused by heart attack or a fatal heart rhythm. So, in a situation where before we felt there was nothing we could do, now we have something we can try.

Which brings me back to the title of this post. Most readers will recognize the saying: “If your only tool is a hammer, every problem begins to look like a nail.” So it happens in medicine. As hard as we try to measure the effectiveness of treatments, and as hard as we try to be careful and scientific about it, we are also prone to the temptation to “do something, even if it’s wrong.” Or more clearly, we’re more likely to do something because we don’t know whether it’s wrong. I think of it as a special application of the ethical principle of the technological imperative: "we can do something, therefore we must." However, it’s also an application of my own comment on ethics: critical decisions are usually made emotionally, and justified rationally afterward.

The thing is, the technological imperative is a fallacy. It does not follow that because we can, we must. In this instance, we must consider how to use this tool, to optimize the benefits it can offer in light of the costs both in resources and in the emotions of patients and families. Indeed, we must consider these questions with any such tool in health care – something we do reasonably well with drugs but not so well with new procedures or devices. And I would argue it is even more important when the circumstances are devastating; for that is when we are most likely to invest our time, resources, and emotional energies in our actions.

So in my own work I watch and wait with families to see if this will help; and I celebrate with staff and families when it does. That also means I grieve with staff and families when it doesn’t; but that’s the nature of my vocation. And I do ask questions, trying to help focus on what can help, and on what extends life rather than simply prolonging dying. And I especially ask this question: is this problem really a nail, or is it just that all we have is a hammer?

Sunday, September 27, 2009

Considering Provider Autonomy and Conscientious Objection

This is adapted from a Lunch and Learn presentation sponsored by my hospital's Ethics Committee.

Our topic is provider autonomy; or as it is often phrased, “conscientious objection.” That is, objecting to some act in professional practice on grounds of conscience.

The standard principles we use in medical ethics are the Georgetown Mantra:

I found myself wondering just we might think of comparable categories from a provider’s point of view.

AUTONOMY: From a patient’s perspective, “autonomy” is a matter of the patient’s rights - primary the rights to choose or decline care, and to participate in decisions.

We would also say that a provider has “autonomy” – rights in exercising professional judgment. As a general principle, a professional has the right to accept or not accept a patient, and not to provide inappropriate care. For example, these are the provisions of the American Medical Association’s (AMA) Code of Medical Ethics:

(3) In situations not covered above [emergencies, what the AMA calls “invidious discrimination,” and certain contractual arrangements], it may be ethically permissible for physicians to decline a potential patient when:
(a) The treatment request is beyond the physician’s current competence.
(b) The treatment request is known to be scientifically invalid, has no medical indication, and offers no possible benefit to the patient (Opinion 8.20, "Invalid Medical Treatment").
(c) A specific treatment sought by an individual is incompatible with the physician’s personal, religious, or moral beliefs. (From section 10.05)

A similar provision is found in the Code of Ethics for Nurses of the American Nursing Association (ANA):

Where nurses are placed in situations of compromise that exceed acceptable moral limits or involve violations of the moral standards of the profession, whether in direct patient care or in any other forms of nursing practice, them ay express their conscientious objection to participation. Where a particular treatment, intervention, activity, or practice is morally objectionable to the nurse, whether intrinsically so or because it is inappropriate for the specific patient, or where it may jeopardize both patients and nursing practice, the nurse is justified in refusing to participate on moral grounds. (From Section 5.4)

NON-MALEFICENCE: This is our expression of the principle, “First, do no harm.”

From a professional’s perspective, we have a clear image of what harms a patient. Indeed, one of the clear categories in which a professional can refuse to provide an intervention is when the intervention will harm the patient. However, in the most common situations where conscientious objection becomes a matter of contention, it is because the patient is convinced that the given intervention will not harm the patient, but instead will provide benefit.

That raises another question: what harms the professional? What are the risks that the professional faces – personal, financial, legal, moral? Many physicians, certainly, have anxiety about lawsuits for inappropriate care, and most commonly for not providing enough care or that one alternate intervention. A few providers have faced physical risks in their practice, and in their choices about interventions to provide or deny. We are familiar with the recent death of Dr. George Tiller, assassinated by a person who felt justified by Dr. Tiller’s practice of providing abortions in less than perfect circumstances. However, it applies no less to the doctors and nurses who served AIDS victims before we knew what it was; or to the doctors and nurses who have taken care of swine flu victims before we knew its mortality rate.

Which brings us to BENEFICENCE: which for patients we traditionally phrase as acting in the patient’s “best interest.” Again, professionals may run into conflict with patients about the patients’ best interest.

That said, we can ask the question as to what is in the best interest of the professional. Most often we consider answers to that question that are about income or about freedom to practice. Those are enhanced by the licensure, registration, and certification that limit the number of competitors in our various practices. What other categories might be appropriate? For example, what is in the best interest of the professional’s integrity? What about social benefits of professional practice? We do, after all, receive a certain level of social benefit as professionals, a certain level of social standing.

JUSTICE is the final category of the Georgetown Mantra. I usually contrast this with Autonomy. If Autonomy is about the patient’s rights, Justice is about how this affects the rest of us. So, it is under the category of Justice that we discuss limited resources, costs of care, and other social concerns.

Justice is also an issue for providers. While there is Autonomy in practice, there are also professional expectations of service. It comes under the broad category of “fiduciary responsibility,” which is not solely about money. The word is based in the Latin for faith, fide; and it speaks of keeping faith with the patient and acting in the best interest of the patient, even if it is not in the interest of the provider.

This is also expressed in the Codes of Ethics of the various professions. There are limits to autonomy in professional practice. The various codes of ethics agree, for example, that there is a requirement to provide care in an emergency that transcends the principles of the provider. Consider, for example, the passage above from the ANA Code of Ethics for Nurses. After noting that under appropriate circumstances, “the nurse is justified in refusing to participate on moral grounds,” the very next sentence states, “Such grounds exclude personal preference, prejudice, convenience, or arbitrariness.” In a similar vein, we can note that the passage above from the AMA Code of Ethics is from a section titled, “Potential Patients.” The implication is such decisions can be made before the doctor-patient relationship is established. Once established, however, the doctor’s fiduciary responsibility limits autonomy. So, “Opinion 8.115 - Termination of the Physician-Patient Relationship” states,

Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured.

Note this principle that when a professional wishes to decline care there is an obligation to assist the patient until an alternative is found, and perhaps to assist the patient in finding that alternative. Paragraph 5.4 of the ANA Code concludes, “The nurse is obliged to provide for the patient’s safety, to avoid patient abandonment, and to withdraw only when assured that alternative sources of nursing care are available to the patient.”

So, where does this leave us? We use these categories to consider the ethical principles that serve the needs of patients. Do these categories give us a framework in which to discuss provider rights and conscientious objection? How would we analyze specific instances in these categories? What do you think?

Sunday, September 20, 2009

A Church for Adults

Some years ago I was speaking with a dear friend about his marriage and his future family. We talked about the couple and their plans for children. Being a priest, I also asked about their worship. My friend, raised in a Southern Baptist Church when it was still a bastion of freedom of thought, said, “Well, I’m sure we will join the church when we have children. I certainly want them to learn to live ethically.”

Now, I had and continue to have two problems with this statement. The second, as you will imagine, was the thought that the only point of the Church was to teach good morals. However, I was also struck by the first: the thought that participation in Church was determined by the needs and interests of children.

I’ve seen that attitude lived out often enough. We’ve observed it for years in families that fell away as soon as the youngest child finished the Sunday School curriculum, or left to go away to college. The most egregious case I recall was the parents who timed their Sunday morning tennis to coincide with Sunday School. Two children were dropped off at the back door of the parish, clean and polished and well dressed. Their parents, in their tennis whites and court shoes, smiled, waved them on, and drove off to the club. They were, though, quite observant and punctual: they had finished their play and were waiting again in the car when the children came out an hour or so later.

I was not raised that way. As soon as my parents thought I could stay home alone without burning the house down (at a young age that would be thought scandalous today), I was responsible for my own church attendance. After all, the church we attended was just under a block away. I could walk there easily and safely. If I wanted to stay home, I could. However, if I stayed home, I stayed home alone. My parents went to church with or without me, because it was important to them. Church wasn’t dependent on the needs or the interests of the children. Church was for adults.

This has long seemed to me a principal we might explore. What would it mean if we understood that Church was for adults? I mean, how far could we take that? It convinced me at an early age that Church was worth my time and effort; for as a child what did I want to be but an adult? I have speculated before about not allowing children to attend worship until they were sixteen. However, that was reflecting on the supposed power of exclusion, a power I did not and do not think the Episcopal Church would embrace. Rather, what would a Church for adults look like?

Certainly, it would engage in adult Christian Education. That might seem obvious, and yet as a supply priest I have seen many congregations that offered little if any. Many times I have heard concerns about having a Sunday School program for children, as much to attract their parents as to teach the children. Too often I have heard little about educating adults in Christian living. I am one who thinks many of our current difficulties have come because too many of our lay people have had too little education about the faith as this Episcopal Church has received it. As a corollary, I think too few have had the opportunity to be engaged, to share their own questions and thoughts as part of the educational process.

I think such adult education would be made available to high school and perhaps even junior high students. I’m not thinking here of intergenerational events, as valuable as they might be in themselves. Rather, I’m thinking of that those adolescents who are so close to adulthood, and from whom we are expecting more and more mature behavior, should see it modeled in the adults with whom they worship. They need to see that in this Church adults are seeking to grow in faith. They also need to see adults raising questions about the faith, and discussing those questions with one another, as acceptable within the context of our life together. In Church and out we need them to see how Christian adults live out their faith; and we need them to see it from all the congregation, not just the youth work “experts.”

What else might be characteristic of a Church for adults? Well, adults should be able to address difficult issues, both of life and faith (an artificial distinction, to be sure). It would encourage independence of thought. There are those who understand “receiving the Kingdom like a child” as mandating avoidance of hard issues, and repetition of core articles of faith. However, in my experience children aren’t that trusting and credulous, at least initially. Adults aren’t usually, either; except when faith communities try to circumscribe the explorations of members. A Church for adults would face, and not shy away from, difficult issues.

And in facing those issues a Church for adults would manage discussions that were civil, intelligent, and mutually respectful. We tend to think that adults are able to be thoughtful, and to discuss and disagree; or at least we tend to think that behavior is adult (because not all people of age behave that way). So our debates and discussions should be serious, and also engaging; passionate, and also enlightening. (I’ll admit that I think that at our best we Episcopalians can do thoughtful discussion quite well; but I don’t think we’re alone in that.)

These are just some initial thoughts. What would you think would be the characteristics, values, and value of a Church for adults?

Friday, September 18, 2009

Outrage at Episcopal Cafe

My newest piece is up today at Episcopal Cafe. It is my expression of outrage relevant to the issue raised of health care for illegal immigrants. Of course, as my regular readers will know, I'm not outraged at the same things as the shouting critics.

So, link over to the Cafe. And while you're there, read what my colleagues have written there, and take the trouble to leave a comment. We want to reflect good ideas and good discussion in and about the Episcopal Church, and we want it to be as wide as possible. So, come and see.

Saturday, September 12, 2009

Suggested Reading

I don’t often comment here on what I’ve been reading. Well, that’s not exactly true. The fact is that I don’t read for recreation as often as I might, and then for escape and not edification. I spend an awful lot of time reading on line; and so perhaps I do comment here on what I’ve been reading.

That said, I did read a book this summer that I can recommend. I found myself reading Perfectly Imperfect by Lee Woodruff, and I enjoyed it. I received the book when she was the featured speaker at a fund raiser for my hospital.

Now, I’m no better than anyone else at reading books I receive in such circumstances. However, I had an opportunity before I gave the invocation (yes, I do find myself singing – er, praying – for my supper, as it were) for a good conversation with her. It was clear that she had had good experiences with chaplains when her husband Bob was in the hospital. You may remember that Bob, a correspondent for ABC News, was injured in Iraq, and recovered after a long hospitalization. Speaking with Lee I had some sense of what she felt she had learned in that experience about caring for families in such difficult circumstances. She particularly suggested I would be interested in the last chapter, “What I Know Now.”

So, I did read the book, and I did enjoy it. It is certainly honest and self-revealing. While I think most of her readers will be women, it is a book I can recommend to men – just be prepared for a woman’s observations about us, and about things in the lives of women that we don’t usually hear about. Lee was as engaging in print as she was in person, and in a way I felt honored, feeling that sense of intimacy when a personal story is shared.

But she was right about the last chapter, and I can especially recommend it, for readers in general but especially for chaplains and other clergy. Indeed, if I were still in that business, I think I would recommend it for CPE students. She confirms some principles of providing support that I have seen over the years - like, there are no magic words; and think before speaking of God in “all of this.” She has clearly thought through what was helpful to her, and what she has seen as helpful to others. In chaplaincy we say often that our patients are our best teachers. This last chapter, “What I Know Now,” is just that sort of opportunity.

So, take the time to read Perfectly Imperfect; and not just the last chapter. We are honored when individuals share with us the stories of their lives. That sense of being honored can blend with a distinct sense of pleasure in reading Lee Woodruff’s book.

Wednesday, September 09, 2009

Health Care Reform and the American Character: Reacting to the President's Address

All right, let me get down to brass tacks. Yes, I did watch the President’s address to Congress on health care. Some quick thoughts.

First, I was pleased. No, it wasn’t all I might have hoped for. Those who have read here regularly will know that I lean toward a single payer option. However, it was a doctor some years ago who said to me, “Don’t let perfect become the enemy of good.” That is, don’t get so hung up seeking perfection that you don’t do what good you can.

Second, this is clearly more about reforming and regulating insurance than about health care practices. That said, finding money to carve out of existing Medicare and Medicaid spending does have something to do with health care practices. While he didn’t use the words “medical effectiveness,” the thought was there. Now, in fact everyone in practice wants to know what treatments are effective, and among competing treatments which are more effective. I don’t know a doctor or nurse who doesn’t want to provide the most effective care possible.

I also know that this will be a challenge to the pharmaceutical and medical device industries. I think it’s a good challenge. There are those who claim that this is one of those things that will “stifle innovation.” I think that, on the contrary, it will stimulate innovation. Adding a decongestant to an antihistamine and patenting the “new combination” isn’t innovation. Reformulating a 4-hour dose to a 12-hour dose and patenting a “timed-release” dosage isn’t innovation. What we need are a new antihistamine that works in a different way, or a new antibiotic, or a new surgical procedure that uses less blood – these are innovation. Measuring effectiveness, and using first for each patient and in each situation the therapy that has been shown most effective for most folks, will focus our directions for innovation. We will, after all, need alternatives for second-line treatments and for patients with special needs. We just won’t use them except where they’re the justified choice.

Third, we can do it. More to the point, we can afford it. Affording it is a matter of political will, and not of absolute limits. The President put that in perspective when he compared generally the cost of this plan with the costs of the wars in Iraq and Afghanistan, and when he compared it specifically with the tax cuts for the wealthiest under the last Administration.

What makes that hard for some folks is the fear of one change or another on top of our current system. In fact, though, these changes will significantly change the landscape. For example, if we can effectively provide universal access to health care for all citizens, we can also largely eliminate cost shifting, that percentage providers must add to cover unreimbursed care. That, then, will in itself slow cost increases. Slowing cost increases slows what we pay for coverage, both in premiums and taxes. Or, we can realize that we pay for all this care one way or another. If we pay more in taxes and less in premiums, we’re not paying more over all. And if we involve the greatest number of people in the system, both as user but also as contributors – that’s what the employer and personal mandates do – we minimize relatively what each of us individually has to pay over all. The point is that these things are all connected, and improving one aspect has ramifications for all.

Fourth, I am glad the President presented this as a moral challenge. I’m especially glad that he raised as a counterpoint to America’s cult of individualism that other American tradition of concern and support for one’s neighbor. In my childhood community barn-raising and neighbors clearing land together were as much a part of American cultural history – indeed, more – than the ideal of the rugged individualist. I was raised not on the image of the gunslinger but of the volunteers who fought together at King’s Mountain and at New Orleans; on community action and not on individualism. For the better part of a generation politicians have played held up (small “l”) libertarian ideas in ways that played to individual greed, and that divided us into ever more fragmented clusters of “us and them.” They obscured those generations of Americans who knew how to balance “what’s in it for me?” with “We the People.”

So, the speech is over, and tomorrow morning the politics begin again. Please God, the Senators and Representatives will have listened, and will have been moved. Please God – whether they believe in God or not – they will see this as an opportunity to reflect their own characters in ways that support the President’s vision of the American character.