It’s an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. “What the hell was that?” someone asks. “Why does that doctor get cuts?” “Oh, that wasn’t a doctor,” Pete says. “It was God. He just likes to play doctor once in a while.”
But it’s no joke. Whereas I don’t buy the “playing God” aphorism, I’ve had to make life-and-death decisions on occasion, and I don’t like it. I mean “life and death” literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance — looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable — is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?
Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it’s fatal. In operating, one may find — depending on the cause and the anatomy — a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.
And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it’s conceivable that two people might make different decisions; ergo, it’s subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you’re not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?
I’m sure most of you have heard it before, or something similar — but as you know there is a significant possibility that the number of residency positions available nationally could be cut. Seriously? This just doesn’t work for me — especially when combined with a mandate out for medical schools to increase their class size by 10%. All this will do will cause a flux of students who can’t complete their training!
Lets get some background on the issue — the Congressional Supercommittee was contemplating cuts to federal funding for residency programs by more than 50%, it is imperative that we, as future physicians, make our voices heard on Capitol Hill.
If Congress reduces Medicare Graduate Medical Education (GME) funding, a recent survey of residency programs suggests that there will be significant reductions in the number of residency positions available with some programs indicating that they will be forced to shut down altogether. Such a dramatic reduction in training opportunities will reduce Americans’ access to care at a time when we need it most.
In August — our beloved Congress passed the Budget Control Act of 2011 which created the Joint Select Committee on Deficit Reduction, otherwise known as the “Supercommittee.” The Supercommittee, comprised of six Democrats and six Republicans, is charged with developing recommendations to reduce spending by $1.5 trillion in the next ten years. The Supercommittee was supposed to make its recommendations by November 23, 2011, which it failed to do.
So now what happens when these deadlines aren’t met? Well, since the Supercommittee recommendations weren’t met, there will be an automatic sequestration – or across-the-board cuts – totaling $1.2 trillion with 50% taken from defense and 50% taken from other spending. In the sequestration scenario, most of Medicare, Medicaid and Social Security funding will have cuts from next year until 2021.
How much of a cut may occur? Well.. Last year, the President’s “Deficit Commission” recommended slashing Medicare Graduate Medical Education (GME) funding by more than 50%. So if that’s the case, then what do we do now? Perhaps we can ask Congress to repeal the Budget Control Act altogether? I think us as physicians, and physicians-in-training, should contact our representatives and senators and do something about this.. I already have, will you?