I'm on service this week-a time honored exercise in which I, as the attending physician, listen to trainees and students present cases that we have been asked to see in consultation or who have been admitted to the ward cardiology service for poor folks with Medicaid or no health insurance at all. I visit each patient, make sure the trainees don't do anything foolish, try to do a little teaching, and philosophize in the style that you have so graciously tolerated in these pages. With the current health care argument before SCOTUS front and center this week, its been a challenge to keep my frustration with the present state of affairs out of the conversation. The trainees have to listen to whatever I say and pretend to be interested, so I try to make sure I don't bore them.
With the accumulation of gray hair, among other elements of inevitable decline, I no longer believe that the most important contribution I make in this ritual is the medical stuff. "This is the thigh bone, this is the leg bone, this is the knee that joins them", that kind of thing. My young charges, who are all plenty smart, can, and will, learn that from books or someone else. I am much more interested in getting them to be comfortable with the inevitable uncertainty that accompanies medical decision making, and to see the larger consequences of their decisions. What is the benefit of dialysis (30K/year) or an implantable defibrillator (50K) or any other of the myriad fantastical treatments that the medical industrial complex dishes up year after year to a demented bed ridden 85 year old? Is more treatment always the answer? Who benefits really?
A terrific op-ed this week from our favorite leftist newspaper reprises the dismal statistics: 1/3 of Medicare expenditures take place within the last 6 months of life, and a 1/3 of that takes place within the last month. Since when did it become a requirement that the dying be poked, probed and inserted with every possible catheter like Ahab lashed to the mast in search of unobtainable immortality? How is it that our culture decide that death is an option, like leather interior or extra leg room?
Eventually, as you like to say, this will end because it must. We ration now and we will ration
more in the future. Its just a question whether we will do so with any interest in fairness.