I seem to be having long discussions about health economics and ethics this month. Who should have expensive preventative treatments? At what point should you decide in advance to let a toe, a foot or a person die?
Maybe it’s the time of year. Maybe it’s the rotation I’m doing (Vascular Surgery). Maybe it’s because my perspective has changed. I’m more senior now. I deal with common surgical problems with less anxiety. This just means I can spend more time worrying about “doing the right thing” by my patients.
Vascular surgery is often about prevention rather than cure. We act to prevent someone needing an amputation. We operate on aneurysms to prevent them breaking open, which often causes the patient’s death. We open up blood vessels to prevent things getting worse later.
The difficulty comes in deciding who is too sick. In which patients should we let the complications happen? The patient with dementia who still recognizes her daughter, but may have a shorted life? The patient with advanced cancer who still lives at home independently with his wife? The young patient who has multiple medical conditions and only partially complies with medical advice? The heavy smoker? The alcoholic? The patient we don’t like?
I guess this isn’t about the season. I reckon I’ll be having these conversations with anaesthetists and intensive care physicians for the rest of my career.
At the moment I don’t make the final decision. What do I do when I disagree? If things turn out ok, does it mean I was wrong? No idea.
Oh dear, there are actually patients that are not likeable? Iol It’s so hard to be compassionate and objective isn;t it? and no, you are never wrong when you care, you are never wrong to disagree and never wrong to be passionate about helping people. Keep the Love flowing freely through vascular surgery I say 😉
@Ixchelbunny:
There’s surely people everywhere who aren’t likeable. It would be pretty uncommon for it to affect their treatment, but it no doubt changes the way medical staff hunk about them. I know it is frustrating to decide to withhold treatment from a patient you like and hen have to stand by the next bed and convince the guy/girl to accept it.
I’m lucky I mostly like my patients. It makes figuring out their best interests easier.
Everyone expects that as you become more senior and more experienced that everything becomes easier. Unfortunately the reality is that you start seeing the complexity of the bigger picture, and every time you think you have a problem licked then you suddenly realise that there is another set of problems that you never realised existed.
Unfortunately health economics are a core part of modern medicine, for as long as a party other than the patient is paying for their care. Even when the patient is bearing the full cost of their care, professional ethics binds you to do what you think is best for the patient, and that includes their financial wellbeing as well as their psychosocial and physical health. How is that for another can of worms?
We underestimate the importance of prophylactic surgery and therapy. It is easy to understand performing a simple procedure to relieve pain or remove a disfiguring lesion. As an extension it is then easy to understand a procedure to remove a malignant cancer. What happens if the procedure is not so simple? Or if the lesion is pre-malignant? A whole series of value judgements come into play, by the patient, by yourself, and by population health decision-makers. These are the issues you are starting to see come into play, now that you have a better grasp of the technical aspects of surgery.
Trust me, you will be struggling with these decisions for the rest of your career. Either that or you will become a cosmetic surgeon. 😉