Alert and Oriented

Good medicine starts with friendship

Michel AccadNovember 20, 2015December 13, 2016Ethics, Medical practice, Philosophydoctor-patient relationship, friendshipLeave a comment

Whenever I have the opportunity to suggest that good medicine is based on friendship, I usually get a nod of approval mixed with a quizzical look. What’s that supposed to mean?!

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!”Continue reading “Good medicine starts with friendship”

How to safeguard your career in a treacherous healthcare environment.

Michel AccadNovember 13, 2015September 10, 2021Ethics, Healthcare economics, Medical practice, Medical science, Philosophy7 Comments

[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.Continue reading “How to safeguard your career in a treacherous healthcare environment.”

Is assisted suicide “medically necessary?”

Michel AccadNovember 10, 2015December 13, 2016Ethics, Healthcare economicsphysician-assisted suicide2 Comments

André Picard, one of Canada’s foremost healthcare journalists, published an article today in which he analyzes the funding rationale for his country’s healthcare system.

Canada has the most singularly bizarre health-funding model in the world. It is, to use the technical term, bifurcated – meaning there are two distinct categories.

“Medically necessary” care, defined as hospital and physician services, is paid 100 per cent from the public purse. Selling these services privately is, with few exceptions, illegal or subject to punishing penalties…

The rest of health care is, by default, not deemed medically necessary, but still gets varying degrees of public funding. Only about 6 per cent of dental care is paid publicly, as are almost half of prescription drug costs, and about two-thirds of long-term care costs.

Given Canada’s perennial healthcare budget deficits and notorious waiting lines for medical care, Picard adds:

Getting the mix of public and private care right means ensuring everyone has access to essential care in a cost-effective manner, and still allowing patients a modicum of choice, and the ability to supplement their publicly funded care with other services.

At some point, we have to make some clear, coherent decisions to ensure that happens. Doing so begins with asking, and answering, the question: What is really “medically necessary”?

The final question Picard asks couldn’t come at a more opportune time.Continue reading “Is assisted suicide “medically necessary?””

The suicide Robin Williams was denied

Michel AccadNovember 4, 2015December 13, 2016Ethicsphysician-assisted suicideLeave a comment

The autopsy performed after Robin Williams committed suicide showed that the actor had widespread Lewy body disease. His widow Susan just revealed that information and told reporters that depression was only a small part of the myriad of frightening and incomprehensible symptoms that beset him for more than a year before he took his life. As the disease progressed, he suffered from impaired movement, anxiety, paranoid thoughts, and depression.

Last month, Governor Jerry Brown signed into law a bill that allows doctors to prescribe a lethal medication to terminally ill patients who wish to end their lives. In the letter he issued as he signed the bill, he wrote: “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

But apparently, Jerry Brown and those who support the law would deny “that right” to people who, like Robin Williams, suffer from Lewy body disease.Continue reading “The suicide Robin Williams was denied”

How doctors became subcontractors

Michel AccadOctober 27, 2015December 13, 2016Healthcare economics, Healthcare policy, Medical practicedoctor-patient relationship2 Comments

During my recent podcast interview with Jeff Deist, president of the Ludwig von Mises Institute, I remarked that third-party payers are not, in fact, intermediaries between doctors and patients. In reality, it is the physician who has become a “middleman” in the healthcare transaction or, as I argued, a subcontractor to the insurer.

Important as it is, this reality is not well recognized—not even by physicians—because when doctors took on this “role” in the late 1980s, the process by which healthcare business was conducted did not seem to change in any visible way.Continue reading “How doctors became subcontractors”

At the tribunal of Jerry Brown’s conscience

Michel AccadOctober 21, 2015December 13, 2016Ethicsphysician-assisted suicide2 Comments

When California Governor Edmund Gerald “Jerry” Brown, Jr. signed into law ABx2 15, legalizing assisted suicide in the state, he issued the following statement explaining the reasoning behind his decision:

In his 1993, John Paul II had this to say about the kind of examination of conscience through which Governor Brown would become “certain” about the comfort that the law would provide him and others:Continue reading “At the tribunal of Jerry Brown’s conscience”

Neither expert nor businessman: the physician as friend.

Michel AccadOctober 15, 2015December 13, 2016Ethics, Healthcare policy, Medical practice, Philosophydoctor-patient relationship, friendship, outcomes2 Comments

In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument? For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!Continue reading “Neither expert nor businessman: the physician as friend.”

Five hopeful trends in medicine and healthcare

Michel AccadOctober 8, 2015December 13, 2016Medical practice3 Comments

I feel that I have been spending way too much time as a “chronicler of the decline,” to use von Mises phrase. The secular trend in healthcare (literally spanning the last 100 years) is one of increasing centralization, consolidation, and reduced choice. Nevertheless, there are some promising developments that gives me hope for a better future.

Here are five notable trends, in no particular order:Continue reading “Five hopeful trends in medicine and healthcare”

Shortages and price gouging

Michel AccadSeptember 25, 2015December 13, 2016Healthcare economics2 Comments

The shaming campaign that followed the news of two generic drug prices somersaulting into the stratosphere after being acquired by private companies is not too surprising. The idea that a drug which cost $13.50 one day can cost $750 the next, seemingly on the whim of greedy Wall Street investors and pharma start-ups, is fodder for the outrage machine.

But what the outrage machine does not realize is the extent to which the generic healthcare supplies are constantly on the brink of shortage.
Continue reading “Shortages and price gouging”

One hundred years of managed care

Michel AccadSeptember 10, 2015September 10, 2021Healthcare economicseconomic history8 Comments

[This is the wrap-up to the series on the economic history of the American healthcare system, the first installments of which can be found here and here.]

The term “managed care” entered the common lexicon in the 1990’s, when contracted arrangements between physicians and hospitals on the one hand, and insurance entities on the other, became standard means to try to control healthcare expenditures. The origin of the concept is frequently credited to Dr. Paul Ellwood and his influential Jackson Hole Group, who introduced the idea in the early 1970’s.

But in our 2-part series on the economic history of American medicine, we saw that healthcare has been “managed” from its inception in the late 1910’s, when the Flexnerian reforms and the ensuing medical licensing laws began to influence (and limit) the type of medical care Americans could choose to receive.

Since that time, an ever-growing managerial class of academics, industry leaders, technocrats, and private foundation believers in “systems” and in a “scientific” approach to organizing society has been guiding the various government interventions which have shaped American healthcare as we know it today.(1)Continue reading “One hundred years of managed care”