Demise of the Individual in Medicine

“I worship individuals for their highest possibilities as individuals, and I loathe humanity, for its failure to live up to these possibilities.” – Ayn Rand, “Anthem”

One of the most concerning trends in medicine I see is the movement away from individualism and toward collectivism.

This trend manifests in multiple ways in our medical institutions, arising as such creatures as Evidence-Based Medicine and the notorious use of the Bell Curve (http://statistics.about.com/od/HelpandTutorials/a/An-Introduction-To-The-Bell-Curve.htm) to apply population-based statistics to the treatment of individual patients. While these statistics may be useful for adopting guidelines—i.e. MOST people will have this experience with this drug—attempting to apply guidelines as hard and fast RULES in the medical sciences is rather disturbing.

Many consider ancient Greek physician Hippocrates to be the Father of Medicine, as he lived in the 4th century BC.  A close look at the Hippocratic Oath, which many medical students take upon graduating from medical school, shows the importance of the individual patient above and beyond the concerns of the collective—the community, the society or the State. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html

While the original oath first upholds sacred the community of medical practitioners as a family, it goes on to state that treatment for the sick will never be given to intentionally harm, that is, “according to my ability and judgment, I will keep them from harm and injustice.”

We have embraced this to mean, “First, do no harm.” But when there is a clash between individual concerns and the public concerns, to whom shall the “no harm” be directed? I would fully expect the physician who works for a public health organization (or one with a Master of Public Health degree) to take the stand that the concerns for the public health outweigh that of any one individual. However, it is my belief that for me—as a primary care physician —the medical concerns of the individual are, well, PRIMARY.  If not the family physician, then who will be the advocate for the individual patient?

The Hippocratic Oath goes on: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.” Personally, I interpret this to mean: I will not murder. I will keep private things private and to myself. I won’t take advantage of my position for personal gain.

These are the basic tenants of medical ethics. After the atrocities of the Second World War in the 20th century, it is no surprise that the oath I took with my classmates in 1999 includes refraining from unethical experimentation. If you read about the things that have been done to people in the name of “science,” you wonder how any physician could be encouraged to do such things. Then you find that it was all for the sake of “the good of the People.” The information gained could improve the lives of the Public; therefore, it was OKAY to subject others (particularly those considered to be sub-human) to all manners of experimentation, since it was for the Public Good.

As a modern example, let’s consider the “statin” debate. It is generally accepted in medical circles that statin drugs reduce cholesterol and therefore reduce the incidence of heart disease. Do we truly have a method of preventing heart disease by treating cholesterol levels, or have such a large number of studies (often sponsored by pharmaceutical companies that are developing statin drugs) been performed on certain populations that are sure to show improvement in cholesterol levels? Then, those same certain populations can be followed to see if heart disease develops, in order to create a logic that says “Using a statin reduces heart disease.”

I have trained myself to look directly at the study and see who was excluded rather than who was included as study subjects. This tells me who cannot be considered for a favorable result regardless of the results of the study! Think about it this way: if those individuals were excluded from the study, the designers of the study knew that portion of the population would skew the results away from what they want the study to show.

To further illustrate this, we can go to “Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis” http://www.nejm.org/doi/full/10.1056/NEJMoa0912321#t=articleMethods, the CREST study. Scroll down to “Selection of Study Patients” and look at who was excluded from the study. Then please note the last line of the section: “The full eligibility criteria have been published elsewhere.” Why? Would the eligibility criteria be so exclusive for the study that it may render the study of little use? But no, surely this is only going to be helpful for vascular surgeons to be able to decide whether they need to scrape off plaque surgically (endarterectomy) or place a stent, right? But, if I wanted to know if my patient with carotid artery stenosis (plaque build-up in the carotid artery) should be considered for a stent or an endarterectomy, I would go to the footnote (see that little number 10 at the end of that section?) and read the full eligibility criteria. I would do this specifically TO SEE IF THE STUDY RESULTS WOULD APPLY TO MY INDIVIDUAL PATIENT. I cannot apply population-based statistics to my individual patient because my individual patient may fall out of that Bell Curve!

So, I click on the footnote, and it gives me two choices of where to get the entire article (Design of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST).

I can rent the article to read for $6 (good for 48 whole hours!) I can pay $15 to read it on the cloud or pay $38 to read, print and/or save a PDF file—just to see the full eligibility criteria for the study! So, I rely on what the article in the New England Journal of Medicine (which surprisingly allows access to the full article for free online) tells me about eligibility. Finding the complete facts can be an arduous and expensive endeavor, which is why some physicians rely on drug reps for their information regarding the efficacy of drugs for certain medical end points.

So here we are with physicians having sales representatives tell us why their drug is best at preventing heart disease. But, what if the whole cholesterol theory—stay with me here—is also a medical “certainty” built on the statistics of a few studies that excludes what could be a large part of the population that a physician will be seeing? In other words, what if an entire “disease” could be “created” for which only certain drugs can help prevent or treat? Before I ask you to slip on your tin foil hat with me, realize that it is not so outlandish to suggest this as a possibility.  I nearly threw a drug rep out of my office once for even using the term Chronic Obesity as if it were a disease and not a condition of storing too much reserve energy. But since their drug product was created to address obesity, they need a Disease (with a capital D) with which to associate their product. I asked her how long a patient needed to be on the product and she said, “Oh this is for Chronic Obesity. They have to be on it forever.”

I refrained from explaining to her how the human body naturally works, because I knew she was simply regurgitating what she had been taught to say by her company. By the way…I don’t prescribe their drug!

My argument for having multiple blood pressure medications, even those that work the exact same way in the body, is that what may work for one patient may not work for another, or may have undesirable side effects in one patient and not in another. I have seen this even in the same drug families. Humans are truly snowflakes—the basics are the same, but there are little variations all over our bodies, and that is what we can SEE. There are untold individual variances, chemically and microscopically, which we can only imagine. With that much diversity at the cellular (and sub-cellular) level, imagine the vast variability at all levels at once when it comes to disease process and drug or nutrition intake!

But, as physicians we are supposed to stick to absolute guidelines and certain measuring tools to satisfy some lofty powers that be, guidelines that were established based on the same kind of studies as the CREST study that we looked at above, which has excluded some patients from the study??!!

This kind of “logic”, once one really thinks about it, is not consistent with what we were taught in medical school. We were taught that life is NOT composed of absolutes, but a vast amount of variance that means we can only give it our best guess as to what we should do (if anything) in any given circumstance.

As a direct primary care physician—one paid by the number of members DPC has, NOT the number of patients I see in a day—I do not have any Meaningless Use mandates from the federal government forcing me to follow guidelines.  I can tell you what the recommendations are, whether it is for the care of those with Diabetes Mellitus or for breast cancer screening; but, my pay is not tied to meeting certain bullet points in a bureaucrat’s mandated guidelines. Therefore, I will tell you the guidelines, but if I don’t think those guidelines necessarily apply to YOU, we will discuss our options. I do believe I need to know the guidelines, and I need to know the options; however, it is your decision since your body still belongs to you and no one else.

And, you can trust I’ll roll my eyes or argue in anger whenever anyone suggests I need to consider the good of the community/society/public/world over the good of YOU, the individual. I don’t WORK for the community, society or the public—I work for you, my patient.

 

 

 

 

Looking Forward While Glancing Back

 

While I have been looking to 2016 and our business goals for next year, I have to reflect on the past three years. I started this business January 1, 2013, and we opened our doors March 1, 2013. We have impacted many lives since then, and it is hard to believe it has been three years already.

We have helped revolutionize family medicine. We have taken the concierge model and translated it to the middle class. We have offered true 24/7 coverage for our patients, managed everything from upper respiratory infections to congestive heart failure exacerbations over the phone, cared for patients as remote as the Dominican Republic, removed melanomas and squamous cell carcinomas and provided liver-saving phlebotomies for a patient with hemochromatosis.

We have email consultations, phone and Skype visits and regularly text our patients. We send flowers when our patients are in the hospital, and send a sympathy card when we hear of a loss in a family. When ice covers the streets or floodwaters cover our roads, making it impossible to make the drive to the office, we man the cell phone and send prescriptions electronically.  We make house calls to our patients who are unable to get out of their homes, and we provide these services to our members because they believe enough in our practice, in our business, to pay a membership fee.  We supported, testified for and helped pass House Bill 769—the Direct Primary Care bill, which was signed by the governor this summer. Our members realize and understand that they are the ones who keep the lights on, who maintain a nice office for them to come to and who pay the salaries of all of us who care for them.  It seems the most natural way to provide medical care—folks paying a fair price for all we can possibly provide for them.  Free market medicine works!

We have found that the constraints of having a single office are many; and to better care for our patients, we are looking to become more mobile. We think this would be particularly helpful for our small business owners who could use the presence of their physician at the work site, or for our patients who require a face-to-face visit but find transportation to the Lake difficult. This is why one of our goals for 2016 is to have a mobile unit, and we are considering having a scheduled circuit for physical visits. Most of our patients who have to travel an hour or more have been excited to learn that we want to provide this for them. We are not sure whether this is going to be a reality yet, but planning is ongoing.

If we become mobile, and if our membership numbers grow accordingly, we will need more help at the office in Osage Beach. If our membership continues to grow in 2016, we may possibly add a nurse practitioner to our ranks.

Our mission statement, which is displayed proudly over the reception window in our office, is as follows: to break down the barriers that currently exist in the patient-physician relationship, to restore mutual trust, and to provide excellent individualized primary health care.

My staff and I take that mission to heart, and use it as our measuring device in all that we do. The relationships we build need to be open but professional. The trust must be mutual, as I put my license, the entire business and the livelihoods of the staff on the line with every prescription I write and every bit of advice I provide. And, “excellent individualized” medical care is what I was trained to provide, which means that I do not treat statistics, or consider all patients to fall in the width of the bell curve, but embrace the uniqueness of each individual human being.

Our ultimate goals for the coming year are:

  • To break down those barriers that still exist between the patient and the physician
  • To restore mutual trust and provide excellent, individualized care for all our members
  • To provide these services for more and more patients throughout Missouri
  • To continue to think outside the box

Wishing you all that is good and helpful in 2016, and looking forward to serving you better!!

~Jenny Powell MD                                                                                                                                                                     Direct Primary Care Clinics LLC, Osage Beach MO