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Decisions about managed care are clear-cut--in theory. Add a trusting patient to the scenario, and they get a lot tougher.
Decisions about managed care are clear-cutin theory. Add a trusting patient to the scenario, and they get a lot tougher.
I practice general internal medicine and teach professional ethics at Harvard Medical School. To help students learn about ethics in this era of managed care, I often refer to the thoughts of Plato, Aristotle, and Kant. But for real inspiration and insight, I rely much more on my memory of an irascible old man, Ted Phillips. Let me introduce him to you as I do to my students.
Above is a picture of him taken 10 years ago, sitting with one of his grandchildren. That's when I first met him; I was in my first month of internship, and he was flat on his back in a ridiculously small hospital gown. He'd just been admitted after passing out at a trolley stop. He'd mistakenly taken too many of his blood pressure pills. His hospitalization was short and uneventful, but in that brief time I enjoyed getting to know him. He was a proud man, a retired engineer and professor of communications. After he went home from the hospital, he switched physicians and chose me as his primary care doctor.
From the beginning I was deeply fond of Mr. Phillips, as I believe most of us are of our first patients. They give us their trust so willingly, even though theyand weknow that we are inexperienced and have so much to learn.
Over the next few years, I learned that my affection and attention couldn't prevent Mr. Phillips from having a pretty rough time. Several years after he became my patient, he was suffering the combined effects of a heart attack, new-onset atrial fibrillation, worsening joint problems, and falls. But worst of all were the unmistakable signs of slowly progressive dementia.
He deftly covered his short-term memory loss with false bravado and humor, but he couldn't hide his deep fear of recurring episodes of disorientation. He'd tell me his experiences of waking up and thinking he was at home as a boy in a small town in Illinois, actually seeing his old bedroom before him, but knowing it wasn't real. Occasionally he'd be driving in Boston, turn a corner, and suddenly recognize everything as the Evanston of his young adulthood. He'd be forced to pull over until the sensation cleared.
Over the years, we sat and talked about his symptoms and concerns. Together we worked through the lab data and examinations, which showed there would be nothing to prevent his memory loss from worsening. Mostly we just talked about what was happening to him, how it scared him deeply, and how it affected his family. Through discussing his flashbacks, he soon developed great pleasure in teaching me about life in Illinois in the early 20th century, the one topic on which he remained an expert as his memory in other areas faded.
During our years together, he also began to ask more about me and my life. One day he asked me to give him a piece of paper so he could write down the names of my children. Ever afterward, he never failed to greet me in the exam room with a question about how they were doing, asking about them by name. The fact that he could do this, given his increasing memory loss, always surprised me until one day several years later when I burst into the exam room and saw him staring intently at something in his hand. He quickly and neatly folded what I could see was that same old piece of paper, stuffed it in his shirt pocket, and reached out to shake my hand. And, with a broad smile, he asked by name how all my children were doing.
Soon afterward, quiescent prostate cancer that had been treated many years earlier became active again, and his health began to fail rapidly. Shortly before he diedtwo years ago, at age 80he came to see me. After we had spent most of the visit covering my agenda, he slowly reached into his back pocket and pulled out a tin can, meticulously crushed flat. He had brought it in to ask me if it was okay for him to eat four cans of this particular kind of spinachfor breakfast! It was the only thing that had helped him with his digestion. I have kept the can and cherish it, for it reminds me of the true gift Mr. Phillips gave to me over our years together, the gift that every physician treasures: the absolute openness, trust, and partnership that gives what we do meaning.
The memory of that gift, and of my relationship with Mr. Phillips, seems a tough fit sometimes when I'm conducting seminars on ethics and managed care. Ethics is often envisioned as a cool and calm process of seeking balance between competing values and different visions of what is right and good. Managed care makes us all question how to balance the care of an individual with competing financial and social goals. Somehow, Mr. Phillips trumps my efforts to find that balance and seek consensus and compromise. He is too real; my dedication to him as my patient is still too deep within me to draw upon it solely in abstract terms.
But I don't try to hide Mr. Phillips from my students who are learning about managed care. On the contrary: In one exercise I ask them to play the role of a committee of medical directors of an imaginary HMO. (They love the idea of being in charge.) I then ask them to decide whether they would approve coverage of an expensive new treatment for prostate cancer that results in only a small improvement in quality of life for most patients. The students, proudly wielding their understanding of evidence-based medicine, typically vote to deny coverage so that the money can be spent more wisely on something else.
Then I introduce them to Mr. Phillips. I show the photos of him, and I guide them to appreciate his toughness, his humor, and his tenderness and vulnerability. He is the human condition made real, and he is the one person who is now requesting this new treatment. I see the students' faces darken and their bodies tense up. A brave few still volunteer to deny coverage; they want to stay true to the science and to the demands for stewardship of resources.
I then ask them to consider what words they would use, face to face, to tell Mr. Phillips and his wife that coverage will not be provided. At this point I pause to let everyone feel the silence that washes over the room, a silence that will not soon be broken.
Managed care raises deep questions about what kind of health care we want in this country, and what kind of physicians we want to be. What better time to revisit and refortify the bases in which we ground the very existence of our profession? What a wonderful time to teach medical students and young physicians how to find a way to build trust as we all seek a new sense of moral community in addressing health care's challenges.
The answers to these challenges will not be simple. What I try to leave my students with is the knowledge that the answers should be evidence-based, financially responsible, and community-oriented, but they must also respond to the human need of each patient to trust in his or her doctor. This is a need I want my students, one of whom may one day be at my bedside, to understand, and that's why I ask them to make a "managed care" decision while looking into the eyes of Mr. Phillipsand feeling what it is to be a physician.
The author is grateful to Mr. Phillips' wife, Ann, for providing the photos of her husband and graciously granting permission for their use in this magazine. This article won honorable mention in our 1999 Doctors' Writing Contest.
Steven Pearson. My ethical beacons: Plato, Aristotle ... and Mr. Phillips.