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【medical-news】对话 Robert L. Martensen医生
A Conversation With Robert L. Martensen
A Front-Row Seat as a Health Care System Goes Awry
Dr. Robert L. Martensen has treated an estimated 75,000 patients and says the health care crisis is one of money, people and systems.
Over a long medical career, Dr. Robert L. Martensen, 62, has been an emergency room and intensive care unit physician, treating an estimated 75,000 patients. He has taught bioethics and medical history at Harvard Medical School and Tulane University in New Orleans. After Hurricane Katrina wiped out his home and Tulane professorship, Dr. Martensen moved to Bethesda, Md., to direct the National Institutes of Health Office of History. Recently, Farrar, Straus & Giroux published Dr. Martensen’s critique of the American health care system, “A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era.” We spoke in New York City during his book tour and later on the telephone. An edited version of the conversations follows.
"Most Americans die in hospitals or nursing homes, and neither is configured to take care of dying patients." - Robert L. Martensen
Q. THE KEYSTONE OF PRESIDENT-ELECT BARACK OBAMA’S HEALTH CARE PLATFORM INVOLVES SETTING UP A NATIONAL SYSTEM OF COMPUTERIZED MEDICAL RECORDS. WILL THAT SOLVE OUR HEALTH CARE PROBLEM?
A. Shared electronic records are valuable. They will reduce error. It may save money because it could cut down on duplicate testing. But the health care crisis is of much greater magnitude than that.
In addition to all the issues around health insurance and who pays, we have a system that costs more than any in the world and where almost everyone is unhappy. Patients feel, “Nobody is listening to me.” Hospital administrators are unhappy because the bottom line has become paramount and their mission has gotten lost. The heads of the large professional organizations feel there is no center anymore; it’s just atomized interest groups, hustling and scrambling. Physicians are disgruntled by their inability to practice the way they’d like. Many are quitting.
This is nothing that technology will fix. The problem is money, people and systems. It’s not that electronic records aren’t worth doing. But to present this as the solution is inadequate.
Q. In your book, you particularly criticize the American way of dying. Why do you feel that this aspect of health care is on the wrong track?
A. Most Americans die in hospitals or nursing homes, and neither is configured to take care of dying patients. There’s little palliative care available, and often the payment structure of health insurance doesn’t support it.
So you end up with situations where a 90-year-old with organ failure is brought to an emergency room and the doctors go, “Let’s tune her up.” Or if the patient starts failing at the nursing home, they’ll say: “No one dies here. Let’s get her to the emergency room.” It’s not unusual in the last six months of a patient’s life that they’ll be shuttled between the nursing home and hospital 6, 8, 10 times and subjected to a lot of painful and expensive interventions. The patient is artificially maintained that way until their body gives out.
I’ve done ethics consults for hospitals where patients have been in the I.C.U. for six months. An elderly woman has gone from a serious neurological problem to end-stage renal disease, with no hope of ever being able to move a finger and no one told the family, “Your mom is dying.” When it was finally said, the relatives were furious.
Q. WHAT SHOULD DOCTORS SAY INSTEAD?
A. I think doctors should get comfortable with being realistic. If it is the case, the doctor should bring up the idea that this disease process might be fatal. Right now, we say, “I can’t take away a person’s hope,” as if doctors were bestowing life. You have to support those hopes that are realistic, not this fantasy land.
I’ve seen how a lot of these interventions are inhumane. If you resuscitate an older person, you may break their ribs during C.P.R. If you put them on a ventilator, you may end up sedating them so heavily they are barely conscious.
Q. CAN THERE BE SUCH A THING AS A GOOD DEATH?
A. My father had one. He was a systems engineer. In his 80s, he developed serious pulmonary problems, and he was very savvy about how things can go wrong in complicated systems, which hospitals are. To make sure that nothing was done to him that only technically extended his life, he made sure that his wife, doctor and hospital had copies of his medical directives. He didn’t have an extended period of dying because he avoided being put on a ventilator. My father died comfortable, surrounded by people who loved him. He was lucid till about five minutes before his death.
I think that’s what I’d want for myself, too. It’s not easy to get. I’ve seen situations where people leave specific directives and the hospitals still resuscitate them.
Q. For many years you worked as an emergency room physician. Why that specialty?
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作者:admin@医学,生命科学 2011-04-07 18:33
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