Friday, November 6, 2009

Personal Responsibility, Policy, and the Pancreas

Let us all raise our glasses to the pancreas,
It has never been an organ of distinction --
Though it functions day by day,
In a most convenient way,
It has never had the glory that the liver gets.

Let us all raise our glasses to the pancreas,
Just secretin’ alkaline digestive juices,
Into the intestine
Just to neutralize the stomach acid
That could be remaining on the food

Hey pancreas, hey pancreas,
You are my favorite organ,
Hey pancreas, hey pancreas,
I can’t think of anything that rhymes with organ…

Pumpin’ out from the lovely Isles of Langerhans
Comes the insulin that regulates the sugar in the blood
And that’s why so high I rank it
And I’ll drop a note to thank it
May you never have a cranky pancreas!

Hey pancreas, hey pancreas, have a nice day!

- Heywood Banks, “The Pancreas Song”

Tuesday night I had two patients with the same diagnosis in adjoining rooms. In G-5 was a man in the mid-forties who had sudden onset of abdominal pain. On talking with him, the pain started suddenly that evening, and he had never had this kind of pain before. His social history noted that he drank 6-12 beers each day and had done so for years. He had never sought help for his problem, and had never been through an alcohol rehabilitation program before.

In the next pod was a slightly older gentleman who had been brought in by ambulance. His abdominal pain had started three days ago, and his use of alcohol had not dulled the pain. He had this many times before, and his old records proved that had been admitted for it on multiple occasions as well. When asked how much alcohol he drank daily, he simply groaned and said it was “too much.” That much did seem clear by the odor in the room. (Incidentally, we stopped saying that the patient has “alcohol on their breath” many years ago when the legal eagles pointed out that other beverages can give the examiner the same sensory experience, and to blame the aroma on alcohol without corroborating evidence was to possibly label the patient in error. So now we say that, “the patient has the odor commonly associated with the use of alcohol about their person,” we get a blood test to confirm it, we are uniformly right in our suspicions, and everyone seems much happier.) He had been to detox multiple times, but had always relapsed almost immediately upon his release from local residential programs.

Their shared diagnosis was pancreatitis. Pancreatitis is an inflammation of the pancreas, and it may occur for a number of reasons. People with very high serum quantities of lipids (such as cholesterol and triglycerides) are at high risk. It can also result from obstruction of pancreatic channels from gallstones or tumors, or from intra-abdominal trauma. But in the ED, chronic alcohol use is far and away the most common cause. Symptoms of pancreatitis most commonly include abdominal pain, nausea, and vomiting. Lab tests show elevations in amylase and lipase, enzymes released by damaged organ tissue. (Interestingly, in patients with chronic recurrent disease, so much pancreatic tissue is dead that there may be no enzymes left to release, and blood tests will look normal.) As the pancreas secretes enzymes responsible for digestion of carbohydrates, proteins, and fats, as well as containing cells that help to regulate blood sugar, long-term issues include malnutrition, diabetes, and severe alterations of blood chemistry. There is also a unique complication of pancreatitis known as pseudocyst formation, in which a fluid-filled cavity collects within the organ tissue. This is extremely prone to rupture and infection, resulting in even further complications. Episodes of pancreatitis are assessed using the Ranson Criteria, which was developed in Glasgow in the early 1970s. The higher the score, the greater degree of metabolic derangement and the higher the risk of complications and death. (Friends of mine from England are careful to note that the system was developed in Scotland due to the high rate of alcoholics. My Scottish friends indicate that any measurable score is simply a sign of weakness.)

The other key shared similarity between them was their financial status. Neither of them had any insurance, and so whatever care was to rendered was going to be on the taxpayer’s dollar.

But the main differences between them were equally key. From a clinical standpoint, one patient was potentially salvageable. By assuming responsibility for his own health, going to rehab and staying with the program, the first patient could halt the progression of pancreatic disease and have no further complications. The second has already demonstrated on multiple occasions his failure to follow through with the need to abstain from alcohol, had already suffered irreversible organ damage requiring intensive medical therapy, and with each admission sees his chances of continued survival fall. And from a policy standpoint, the care of the first patient benefits the entire community in keeping him active, keeping him working, and decreasing health care costs. Caring for the second not only incurs costs that should have been preventable if the patient had assumed responsibility for their own health, but also is likely to continue to place cost and resource strains upon not only the health care system, but also the social assistance sector of society as a whole.

I offer this story not only as an example of how doctors do, on occasion, actually consider their role as unwilling stewards of the taxpayer dollars, but to note that this issue of recidivism and responsibility is one of the significant “downsides” of our current health care system, and one that requires thought as we enter an era of health care reform.

The first question, of course, is why this scenario happens in the first place. Why do we not ask patients to pay a price for their actions? The easiest answer is that they already been held accountable in their loss of the good health. But I think that’s overly simplistic, because while it indicates we should feel sorry for them it doesn’t answer why we keep picking them up over and over again at our own cost.

I’m not a theologian by any means, I would speculate that one of the main reasons we continue to provide unlimited care for people despite their own worst intentions is because the religious traditions of this country hold a great belief in the power of redemption. While we may disagree on exactly how one becomes redeemed, most of us hold in common the idea at any time, one can turn away from our evil ways and resume a life of righteousness. Because this can happen at any time, and because the books are not closed on you until you leave this world for whatever comes next, there are an infinite number of chances to turn the soul back to the ways of good…or, in this case, to turn your behavior from that which jeopardizes health and inflicts costs upon others to actions which better fit our collective sense of justice.

I have no issue with the concept of allowing infinite chances for redemption. I believe that honest repentance and atonement for past evils both cleanses the soul and benefits others, and can do so right up to the moment of death. But if cost containment is a goal of health care reform, we have a hard decision to make. One choice is to accept the status quo and move on, recognizing that this portion of the battle to contain costs is necessarily lost (and will likely worsen as we see more illnesses related to behavioral-based health issues such as obesity). The second, at least in the context of justice within the health care system, is to limit the number of second chances one gets before publically-funded benefits are lost.

Don't get me wrong. I am not advocating for the withholding of care from people who genuinely need it, nor of rules or regulations which discriminate by diagnosis. But I strongly believe that if care is provided on the public purse, beneficiaries of that care must exhibit a certain level of responsibility that go with that privilege. I have no problem in the slightest offering someone free medications, rehabilitation services, educational counseling, and medical care when they are initially diagnosed with illness or injury, even if that problem is of their own making. I have no problem in continuing to provide the highest level of care when the patient has exhausted those reasonable means within their power to maintain their own health. And I recognize that there are those out there who would say this is not an issue of personal responsibility, but of cultural conflict, of prejudice (social, economic, racial, clinical, or educational), and of unclear societal expectations for individual behavior. (I actually would give some credence to the latter thought, because as a society we’ve never made it clear that there's any kind of personal accountability for your behavior as it determines the health care you receive.)

But I do have a problem in providing infinite care on the public purse for those who refuse to act responsibly in their own care. And I believe that if health care reform is to offer any expansion of publically-funded health care benefits or a “public option, that policymakers have an obligation to explore the limits of benefits within these plans and if benefits might ever be withheld through enforcing patient accountability. This is especially true if one of the goals of health care reform is to decrease the cost of care.

Granted, limiting benefits based on patient behavior is a lot easier said than done, and I hope to write more about what ideas have been tried, and the difficulties in implementing them, in a future post. In the end, there may not be a practical way to balance personal responsibility with health care reform. We may also conclude that the moral imperative for second chances outweighs the increasing costs of care. But for now, even to see our policymakers thinking about these concepts would be a start in the right direction.

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