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The Point - June 5, 2014

In this edition:

Article #1
Excerpted from "Teaching doctors when to stop treatment," commentary by Diane E. Meier and Health Affairs in The Washington Post. May 19, 2014 — For years I had tried to understand why so many of my colleagues persisted in ordering tests, procedures and treatments that seemed to provide no benefit to patients and even risked harming them. I didn’t buy the popular and cynical explanation: Physicians do this for the money. It fails to acknowledge the care and commitment that these same physicians demonstrate toward their patients.

Patients and families often assume their doctors are trained and knowledgeable about end of life. Patients and families also assume that doctors will tell them when time is running out, what to expect and how best to navigate these unknown and frightening waters. But many doctors don’t do these things. Most, in fact, have no training in this. Medical school and residency have traditionally provided little or no instruction on how to continue to care for patients when treatments no longer work.

Physicians are trained to make diagnoses and to treat disease. Untrained in skills such as pain and symptom management, communication about what to expect in the future and achievable goals for care, physicians do what we have been trained to do: Order more tests, more procedures, more treatments, even when these things no longer help. Even when they no longer make sense.

So how do we fix this? To change behavior, we must change the education and training of young physicians and the professional and clinical culture in which they practice. New doctors should learn about the management of symptoms such as pain, shortness of breath, fatigue and depression, with intensive training on doctor-patient communication: how to relay bad news, how to stand with patients and their families until death and how to help patients and families make the best use of their remaining time together.

Commentary #1
CMDA Past President and Oncologist Al Weir, MD: “The author describes an unusual case history to suggest two important questions: As doctors, do we know how to resist making life longer when it’s no longer likely and instead focus profoundly on making life the best it can be? Do we know how to ask others to help us in this task?

“Sometimes we, and our patients, may cling to hopes that are no longer realistic. Instead, we should be open and honest and help our patients navigate their way through a new truth of life. Such a shift in effort does not come naturally for most of us; time, skills and compassion are required. Palliative care teams are often the best way to supplement the capabilities and time we may be lacking.

“Even experienced doctors should seek to sharpen their skills and become mentors for our next generation, so that these younger doctors may be more adept at compassionate end of life care than we have been.

“Today was an unusual day for me in which I had the privilege of sharing bad news and redirecting life goals with three patients, while a medical student leaned silently against the exam room wall. After the last such conversation I probably surprised him by saying, “You know, though the circumstances are horrible, I actually like having these conversations. In such moments, I can be the one who shares this awful truth with kindness and love. I trust myself to do this better than others, because I really care for them. I did the work to help them live longer. Now things have changed and I can do the work to help them live better.”

Article #2
Excerpted from “How many patients should your doctor see each day?” commentary by Lenny Bernstein in The Washington Post. May 22, 2014 — In light of the allegations that some Veterans Affairs Department health clinics used elaborate schemes to hide the records of patients who had waited months for care, I began to wonder what a normal caseload would look like for an average physician outside the VA system. And if your doctor has a larger-than-average caseload, is he or she able to give you the attention you need?

The numbers are pretty stunning. A 2012 article in the Annals of Family Medicine noted that the average primary-care physician has about 2,300 patients on his “panel”— that is, the total under his or her care. Worse, it said that each physician would have to “spend 21.7 hours per day to provide all recommended acute, chronic and preventive care for a panel of 2,500 patients.”

According to a 2013 survey by the American Academy of Family Physicians, the average member of that group has 93.2 “patient encounters” each week — in an office, hospital or nursing home, on a house call or via an e-visit. That’s about 19 patients per day. The family physicians said they spend 34.1 hours in direct patient care each week, or about 22 minutes per encounter, with 2,367 people under each physician’s care.

In 2012, the Physicians Foundation, a nonprofit group, surveyed 13,575 doctors across the United States and found that 39.8 percent see 11 to 20 patients per day and 26.8 percent see 21 to 30 a day. In an email, Lou Goodman, president of the foundation, wrote that “physicians are working fewer hours, seeing fewer patients and limiting access to their practices in light of the significant changes to the medical practice environment. The research estimates that if these patterns continue, 44,250 full-time-equivalent physicians will be lost from the work force in the next four years.”

Commentary #2
CMDA Member Thomas Eppes, MD:“The article from the Post raises multiple questions and thoughts from multiple perspectives in seeking to answer the question of how many patients a doctor should have under their care. If you are the patient, the answer is easy, one and it’s me. If you are the physician, the answer is enough to survive, enough to ‘bring home the bacon, enough to pay back the loans, enough to meet the requirements of my contract, enough for whatever your financial goals might be, etc. If you are the physician’s spouse, just enough to support the family and still get home to be with them and the kids. We could go on and on.

“The world is creating multiple pressures on physicians to see more patients, more efficiently, more electronically, with higher quality and even perfect quality, at no greater cost.

“Solutions for individuals include abandon ship, to retire, to go part-time, to do concierge practices or to build highly efficient teams. The days of seeing patients on a merry-go-round at full speed ahead are quickly disappearing as we move from volume driven care to quality proven population management. The proven and comfortable model of the past has to be altered in a quantum way as new and unproven ‘solutions’ pop up. It is quite unsettling, especially for those nearing the end of their practice life.

“What did our Lord do? Obviously, if there ever was one under a time constraint it would have been He. Yet He never ran anywhere, and He was fussed at for not being timely by others not being cared for at that moment. Yet the Bible tells us He met every ‘patient’ where they needed to be met.

“As each of us struggles with our individual station in our walk on this earth, we need to be ever mindful that we are accountable to only our Lord for how we meet His calling for our lives. We should each day see each patient encounter as our opportunity and appointment to glorify Him as we do His work on this earth, whether it be one patient, 30 or 100. This is what those who are trusting us to care for them want and deserve. Prayerfully, each healthcare professional can do this only if our eyes are on Him as He gives us the wisdom, energy, grace, insight and stamina to do His will every day.”

Article #3
Excerpted from “Only a court can release Sudanese Christian woman on death row,” CNN. May 31, 2014 — Mariam Yahya Ibrahim was condemned to die by hanging after she declined to profess she is a Muslim, the religion of her father. Sharia law considers her a Muslim and does not recognize her marriage to a Christian. She is unlikely to change her mind despite giving birth in prison, says her husband Daniel Wani, who also is a Christian. Some Western media outlets have reported that Ibrahim would be released in a few days, but her husband said that only the appeals court could free his wife.

Technically, the president of Sudan cannot pardon her, so the judiciary might be the only way out for the government, which is coming under increased international pressure to release Ibrahim. The court convicted her of apostasy and adultery two weeks ago. At the time, she was eight months pregnant. She gave birth to a baby girl this week at a Khartoum prison, where she’s detained with Martin, her 20-month-old son.

Despite languishing in prison with two infants, she’s holding firm to her beliefs, according to her husband. “There is pressure on her from Muslim religious leaders that she should return to the faith,” Wani told CNN. “She said, ‘How can I return when I never was a Muslim?’”

Wani said his wife is a practicing Christian, more so than him. “I know my wife. She’s committed.” His wife, he said, was raised a Christian by her mother, an Ethiopian Orthodox, after her Muslim father deserted the family when Ibrahim was 6.

Commentary #3
Family Physician and Women in Medicine and Dentistry (WIMD) Chair Amy Givler, MD: “Forced faith is an oxymoron – if faith does not come from inner conviction, then it is not faith at all.

“Meriam Yahya Ibrahim, a fellow physician, has shown tremendous courage in not denying her Christian faith. This week, the Sudanese appeals court could rule on her case. Over the weekend, a Sudanese official stated she would be freed within days, but this was denied by the spokesman for the Sudanese foreign ministry. Growing international pressure is calling for Sudan to dismiss the case and free Dr. Ibrahim from prison, along with her newborn daughter and 21-month-old son.

“If not freed, Dr. Ibrahim faces 100 lashes within a few weeks (for the adultery charge) and death by hanging (for the apostasy charge). Ideally, as Islamic law allows, she would have two years to care for her infant before her death, but I am concerned whether, in prison, she will receive the nourishment needed to continue to breastfeed her daughter.

“Of course, being freed from prison doesn’t guarantee Meriam’s safety in a country where many Muslims, including family members, would feel justified in killing a woman whom they perceive as apostate. Refugee status in the U.S. could be authorized by President Obama, or her visa application (filed years ago after she married her U.S. citizen husband) could be expedited by Secretary of State Kerry.

“If there is the political will to do so, tremendous pressure from the U.S. could be placed on the Sudanese government, which receives around one-fourth of its budget from foreign aid. The U.S. gives the largest share of this, mostly through the U.N. ($216 million) for humanitarian aid, as well as $11 million in direct aid to Sudan’s government.”


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