Weekend Reading: Doctors Who Decide, Death Desires, and Decisions

Washington Monthly: Special Deal
On the last week of April earlier this year, a small committee of doctors met quietly in a midsized ballroom at the Renaissance Hotel in Chicago. There was an anesthesiologist, an ophthalmologist, a radiologist, and so on—thirty-one in all, each representing their own medical specialty society, each a heavy hitter in his or her own field. The meeting was convened, as always, by the American Medical Association. Since 1992, the AMA has summoned this same committee three times a year. It’s called the Specialty Society Relative Value Scale Update Committee (or RUC, pronounced “ruck”), and it’s probably one of the most powerful committees in America that you’ve never heard of. ... it’s the committee members’ job to decide what Medicare should pay them and their colleagues for the medical procedures they perform (Haley Sweetland Edwards, 7/2013).

Related, earlier KHN story: Panel Calls For ‘Drastic Changes’ In Medicare Doctor Pay (Rau, 3/4)

The Atlantic: Make Your Wishes Known
Dr. Kenneth Prager, a 70-year-old medical ethicist, was sitting in his office at the New York Presbyterian Hospital waiting for a patient when he got a call from a colleague. He was happy to hear from Dr. Steve Williams, 56, who had trained under him and was now the chief medical officer of a nearby hospital. But he grew uneasy when he began to understand the reason for the call. Most of the time, ethicists handle cases where a family refuses to let a family member go. This was just the opposite. Williams was caring for a 36-year-old patient who was unconscious, and on several forms of life support, but was expected to recover. The patient's family, though, believed it was best to pull the plug (Ashwaq Masoodi, 7/10).

The New Yorker:  How Should Doctors Share Impossible Decisions With Their Patients?
On a Friday evening a few months ago, my mom broke her arm. A doctor in the E.R. told her it was a simple fracture, and put her arm in a sling. The following Monday, though, she called me. She had consulted two surgeons who had a different assessment: the bone was broken in four places, surgery would be quite involved, and the rates of complications were high. … Here’s the thing: I’m a doctor. Strictly speaking, I know what avascular necrosis means. It means the bone can die. It means the blood vessels can be compromised. Which means, again, dead bone. My mom, a cardiologist, knows this too, as does my father, a rheumatologist. But what I meant was: What did it really mean? How would it feel? How was she supposed to make such an impossible decision? (Lisa Rosenbaum, 7/5).

The New England Journal Of Medicine: From Imagine Gatekeeper To Service Provider – A Transatlantic Journey
In Britain, where I trained in surgery, residents feared radiologists. One radiologist was nicknamed “Dr. No,” since his first response was always to deny requests for any imaging other than a plain radiograph. We had no computerized order-entry system, so after rounds, the junior doctor brought requests to the radiologist for discussion. It took flawless knowledge of the patient, a reasonable grounding in clinical medicine, and a certain stoicism to emerge unscathed from these discussions. … When I began a diagnostic-radiology residency in the United States, I was struck by both the abundance of CT scans, MRIs, and technologists and the fact that in nearly all requests for suspected pulmonary embolism (PE), the stated indication was “pulmonary-artery aneurysm.” The two phenomena turned out to be linked by a common thread: U.S. radiologists were service providers, not gatekeepers (Saurabh Jha, 7/4).

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