I am blessed that my mother is in reasonable health with a keen intellect. She’s a prolific reader, politically engaged, and still independent in mind, body, and spirit.
She has fought medical ageism on several occasions. At age 88, after her granddaughter’s graduation from George Washington University, she fell and fractured several cervical vertebrae. She had the good fortune of doing so in front of the GWU medical center, home of an expert group of spinal orthopedists. They preferred that she wear a head brace rather than have surgery at her age. She said “I rather be dead than live with that contraption. Do the surgery”. She convalesced quickly. At 90, she perforated her bowel secondary to C. difficile, necessitating a colostomy. “When does this get reversed?” she asked the surgeon. Upon learning that colostomies are not usually reversed in nonagenarians, she demanded that the surgeon perform the procedure. “I’ll be damned to live with this bag – no way!”. Again, she survived beautifully, and we are all looking forward to celebrating her 95th birthday next week. My mother doesn’t have a death wish – she just wants to live her life as she sees fit.
As dermatologists, we frequently confront management decisions for elderly patients, arguably mostly regarding non-melanoma skin cancers. “Dr. Heymann, what would you do if it was your mother?” is a common question. I tell patients they should be asking me another question first,: “Do you love your mother?” My response to that question might alter my recommendation!” Then I tell them that, yes, of course I love my mother, and I am fortunate that she can make her own medical decisions, based on the facts.
Using basal cell carcinomas (BCCs) as a paradigm, I suggest reading the excellent article by Wiznia and Federman exploring treatment options of BCCs in the elderly. Their key points are: 1) Treatment options may be considered based on tumor characteristics. A morpheaform BCC near the eye would be approached very differently from a superficial BCC of the arm; 2) Given the wide range of therapeutic options, including standard surgery, Mohs surgery, destructive modalities such as electrodessication and curettage or cryosurgery, topical chemotherapy with imiquimod or 5FU, hedgehog inhibitors including vismodegib [or sonidegib], photodynamic therapy, or radiation; and 3) observation, which may be a reasonable option based on the BCC type, location, and life-expectancy of the patient (1). I applaud the author’s conclusion that “given the wide range of therapeutic options for basal cell carcinoma, treatments can be tailored to achieve patients’ goals of care within their anticipated life expectancy.” (1)
As America grays, medicine is under pressure to develop best practices reflecting outcomes, costs, and “value”. Variability in how practitioners manage disease may affect cost and outcomes. According to Soni et al (2)
Variation in clinical practice is substantial and is associated with poorer health outcomes, increased costs, and disparities in care. Substantial attention has been given to reducing unnecessary differences in practice patterns. Despite these efforts, practice variation has been difficult to overcome. Challenges to reducing variation include heterogeneity and gaps in clinicians’ knowledge; economic incentives for undesired clinical behaviors; concerns about malpractice risk; physicians’ value of autonomy and personal preference; inadequate communication and decision support tools; and imbalances between clinical demand and resource capacity. Another fundamental barrier to practice standardization is that good clinical practice must sometimes vary to reflect a patient’s specific social, environmental, and biological situation. Sometimes a standard practice would not be best for a given patient. Hence, efforts to legislate or establish policies governing care have been limited because they impede the common sense that there are nearly always exceptions to a given rule.
The authors detail their experience setting up “Expected Practices” (EP) in the Los Angeles Department of Health Services, which they describe as being “resource-limited” and having a predominance of Medicaid patients. Twenty-five specialty-primary care work groups were established to define the EPs. They state : “The term “expected practice” is used because it is expected that physicians and other health care professionals will follow this standard approach except in rare cases with a compelling justification to deviate based on a specific patient’s clinical situation.”
More than 120 EPs were established on topics ranging from rheumatoid arthritis, hepatitis C, and indications for colonoscopy. A forthcoming evaluation of outcomes and costs will assess the success of the program.
Intellectually, I concur with the need for evidence and appropriate algorithms to provide optimal care to the largest population possible. Emotionally, as a physician who sees one patient at a time, my Pavlovian reflex is to shudder at the concept of the loss of decision-making ability. When is the last time you were pleased to complete a prior authorization for a drug or imaging study?
Would my mother have been able to have her spinal surgery or her colostomy reversed based on EP criteria? If not, would she have been able to appeal those decisions?
Here is a birthday wish for my mother (and all of us) – may we face the coming heath care challenges with intelligence, grace, and compassion. Let us learn to make the best decisions for all populations, with ultimate respect and appropriate decisions for the individual.
I love you Mom!
- Wiznia LE, Feuerman DG. Treatment of basal cell carcinoma in the elderly: What nondermatologists need to know. Am J Med 2016. April 1 [Epub ahead of print]
- Soni SM, et al. Development and implementation of expected practices to reduce inappropriate variations in clinical practice. JAMA 2016; 315: 2163-4.