I was kindly asked to provide an article for Courrier du Medecin Vaudois, the French language journal of the medical society of the canton of Vaud. The article was published as part of an issue on the theme of ‘America First against Obamacare.’ Below is an English version of the piece.
Health care in the United States: The surprising good news
On the surface, the news from America about health care seems rather grim: cost and dissatisfaction keep rising, reforms are stalling, and, for some, even life expectancy may be declining. If that wasn’t bad enough, President Trump issued a tweet on March 25 predicting that “Obamacare will explode.”
For a small but growing number of doctors and patients, however, the future is surprisingly hopeful.
The author is Professor of Medical Humanities and Bioethics and Professor of Medicine at Northwestern University Feinberg School of Medicine. Her book is too rich to cover deeply in a short review, but I’d like to highlight some of its major strengths as well as a few minor weaknesses.
In the first part of the book, Montgomery thoroughly demolishes the notion that medicine is applied science.
This article first appeared in the November/December issue of San Francisco Medicine, the magazine of the San Francisco Medical Society. That issue was dedicated to the theme of ‘Thriving in Medicine.’ For other blog posts on the topic of MOC, see here.
Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career. Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise.
To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise.
In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated.
I read your two articles on friendship for more explicit clues on how to deliver very bad news, and wondered if you would consider publishing something on this topic as part 3 of this series. My prompt is a close friend with cancer, and she’s not getting better. At her last visit, the message she took home was: “there’s not much more we can do for you other than more chemotherapy, and we’re not even sure that it will do any good.” This was a complete and sudden loss of hope.
Two thoughts come to mind.
The first is from Viktor Frankl. In Man’s Search for Meaning he says: “Those who know how close the connection between the state of mind of a man – his courage and hope, or lack of them – and the state of immunity of his body will understand that the sudden loss of hope and courage can have a deadly effect.”
The second is from Atul Gawande’s book, OnBeing Mortal. He describes two approaches to giving bad news. Dr. Informative supplies hard cognitive information: cold facts, descriptions, outcome possibilities, statistics. A doctor’s other approach might be to look for an opportunity to start the conversation with “I’m worried” and then continue with the patient in an “ask, tell, ask” process. In this approach, the direction of travel becomes clear more gently and perhaps gives the patient a little more time to walk into the possibility than being crashed into it.
…I would be especially interested to read your views from the doctor’s side in the context of your two blogs on the friendship dimension in the doctor-patient relationship.
In this article, I wish to introduce the reader to the theory of entrepreneurship advanced by Frank Knight (1885-1972), and show that the common, everyday work of the physician could be considered a form of entrepreneurial activity in the Knightian sense.
Knight was an influential American economist. He is best known for his book Risk, Uncertainty, and Profit in which he proposed to distinguish risk and uncertainty as follows:
A couple of weeks ago I was interviewed by Kevin Price on his radio show “The Price of Business” which runs on Houston’s 1110 AM KTEK radio station. Also present was Dr. Geetinder Goyal. We talked healthcare economics, free markets, and direct patient care. I hope you enjoy it.
At a recent meeting of an editorial board on which I serve, the reaction to my suggestion was more forceful and perhaps more honest. The topic of the day concerned patient education, and how hard it can be to move patients to do things like exercise more or eat better. I timidly proposed that, as physicians, we might want to start by being our patients’ friends. The physician sitting next to me immediately objected: “I wouldn’t go that far!”
the following post is a slightly edited version of an article kindly commissioned by In-Training, a website run by and for medical students. The advice I give in the article is based on lessons I learned long after finishing medical school, so I hope you will find this piece of interest, even if you are well established in your healthcare profession.
Dear medical student,
I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.
I will not elaborate on why I think the healthcare system is “treacherous.” I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.
I am also not going to give any actual advice. I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions. The real advice will come to you naturally as you proceed to answer these questions for yourself. I will, however, direct you to some resources to aid you in your reflections.
I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.
I have found that reflecting on these questions has been essential to give me a sense of control over my career. I hope that you, in turn, will find them intriguing and worth investigating.