How we do harm
How we do harm
While reading Otis Brawley’s book, How We Do Harm: A Doctor Breaks Ranks about Being Sick in America, there were several aspects of the book that made an impact on me. The aspect of the book that made the greatest impact on me was the realization of how troubled our healthcare system is regardless of one’s stature in society. In Brawley’s book, he gives several examples of where individuals that have insurance receive care that is unnecessary for unjust reasons (Brawley ; Goldberg, 2011). Brawley (2011) also shows examples of uninsured individuals that either do not receive treatment at all until it is too late or the necessary care that is needed is not given to the patient. Both scenarios end in harm to the patient in some shape or form. One usually thinks that being uninsured or having disparities puts you at risk for marginal care. Realizing that regardless of being insured or uninsured in America, the current healthcare system can ultimately harm you. This realization opened my eyes to a new way of thinking about healthcare in America.
A social mandate is when a professional is shaped and formed by the society that called them into the profession. For nursing and advanced practice registered nurses (APRNs), this shaping is most often done by the code of ethics, nursing theories, and healthcare legislation. It requires nurses and APRNs to care about others, provide quality care and promote enhancements in healthcare policy to protect the public (Duncan, Thorne, ; Rodney, 2014). The Affordable Care Act (ACA) introduced programs aimed to improve quality and control the healthcare cost (Salmond ; Echevarria, 2017). APRNs can lead the transformation into this changing healthcare through greater coordination of care, focus on patient-centered care, and quality improvement (Salmond ; Echevarria, 2017). By doing this APRNs can help bridge the gap in healthcare equity, which is acknowledged as part of their social mandate (Duncan et al., 2014). By fulfilling the social mandate, APRNs can provide better outcomes for the patient. Providing better outcomes and quality coordinated care to the patient provides a better healthcare system for the patient.
Brawley (2011) brings some insight into unnecessary healthcare and screenings in his book. Using screening test as a tool to identify a disease or cancer is certainly a valuable tool to have in healthcare. However, there are times when these screening tools are overused and cause unnecessary treatments to be performed on patients. In the book, Brawley talks about a man named Ralph, who is a retired man in his seventies. Ralph had his prostate-specific antigen (PSA) level checked at a free clinic, and it was found to be slightly elevated. Due to this slightly elevated PSA level, Ralph received an array of unnecessary treatments that left him with a reduced quality of life and ultimately ended his life (Brawley ; Goldberg, 2011). Brawley (2011) questions the science behind screening for prostate cancer and the treatment options for prostate cancer. In 2013, the Institute of Medicine (IOM) called attention to the fact that unnecessary services has amounted to an estimated 210 billion dollar healthcare spending in America (Carroll, 2017). This means that the unnecessary care and services are expensive. Brawley mentions that the unnecessary screening and care that Ralph received caused him to become extremely anxious, worry excessively and be emotionally fatigued (Brawley ; Goldberg, 2011). The results of unnecessary screening and healthcare causes excessive cost, distress to the patients, and unnecessary harm both mentally, emotionally, financially, and physically.
A wallet biopsy is a term used in the medical profession when an examination is done on an individual’s wallet to determine if the individual can pay for the hospital stay or the treatment plan. When a wallet biopsy turns up negative, it means that the individual is unable to pay for treatment services. In a recent study, it was shown trauma patients that were insured was less likely to be transferred to a trauma center. Instead, these insured trauma patients were admitted and treated at a non-trauma center for the financial gain of the non-trauma center (Delgado et al., 2014). When a patient is severely injured in the field, it is understandable for the patient to be taken to the nearest non-trauma center to be stabilized. When these patients are not transferred out to a trauma center after being stabilized, they are at risk for increased mortality and decreased care (Delgado et al., 2014). What happens at these non-trauma centers is the center performs a wallet biopsy on the individual. When the center learns that the individual is insured and can pay for the stay and treatment, they choose to admit the patient and collect the reimbursement from the insurance company rather than transferring the patient out. Dr. Brawley gives an example in his book of a time when a wallet biopsy was performed on a patient named Martin. Martin learns that he has colon cancer and begins the treatments deemed necessary by his current doctor (Brawley & Goldberg, 2011). When Martin becomes too weak to go back to work, he loses his insurance coverage, and can no longer pay for his treatments. His current doctor suggest since he can no longer pay for the care, that he should seek treatment at another hospital with another doctor (Brawley & Goldberg, 2011). This same scenario happens today in healthcare. If an individual is unable to pay for their care or services, most doctors and hospitals will not treat them. This situation is unfortunate for the people of America, and if this does not show the need for change in our healthcare system, then I am afraid nothing will.
There are many different types of ethical issues that present in healthcare today. Brawley (2011) talks about several ethical issues in his book, but the ethical situation about Mr. Huzjak stood out to me. Mr. Huzjak was a seventy-eight-year-old man whom Dr. Brawley had the opportunity of treating. Mr. Huzjak was unresponsive to everything but painful stimuli when Dr. Brawley met him (Brawley & Goldberg, 2011). Mr. Huzjak also had been diagnosed with stage four lung cancer, and it was apparent to Dr. Brawley that this was the end of life for Mr. Huzjak. Mr. Huzjak’s family was present with him, and after having a lengthy discussion with Dr. Brawley about Mr. Huzjak’s condition and treatment options, the family insisted on their father being a full code (Brawley & Goldberg, 2011). This creates an ethical issue. Due to the family’s decision to make their father a full code, Mr. Huzjak is put through several lifesaving treatments that in the end were not enough. It is difficult for families to withhold treatment for a loved one because they are not ready to accept the fact that their loved one is dying. Although it is a difficult decision to make, patient’s family members should put their self-interest to the side and focus on what is best for the patient’s interest (Karnik ; Kanekar, 2016). Good communication and constant education from the physician can help the family understand the condition as well as the nature of the disease. By having the correct information and knowledge, the family can make informed decisions about their loved one’s care.
We live in a culture that thinks more is better when it comes to healthcare. Brawley (2011) details an example of this culture in his book. He tells of a woman, Debbie, who is a forty-seven-year-old woman diagnosed with Dukes’ A colon cancer. Debbie had the cancer removed surgically and referred to an oncologist (Brawley ; Goldberg, 2011). The oncologist suggest a yearly colonoscopy, computerized tomography (CT) in six months and yearly, and blood work yearly. Debbie is adamant that she receive chemotherapy because she needs to be certain that all the cancer is gone. The oncologist refuses. Debbie eventually finds a doctor that gives her chemotherapy (Brawley ; Goldberg, 2011). Debbie is unaware of the risk and the harm she is posing onto her body years to come. Brawley (2011) points out that this idea of more treatment or overtreatment is becoming a norm in today’s society. What our society needs is an approach that looks at doing more for the patient while doing less to the patient (Grimm & Saini, 2015). This can be achieved by educating the American people to change their way of thinking and ultimately the current culture of more is better.
Many health policy issues exist today. One that Brawley (2011) discussing extensively and is passionate about is health promotion and screening. Throughout Brawley’s book, he mentions that not all health screenings are live-saving (Brawley ; Goldberg, 2011). Brawley assisted the American Cancer Society in writing their recommendation for prostate-cancer screening guidelines (Brawley ; Goldberg, 2011). Brawley (2011) also assisted with clinical trials in the testing of prostate cancer treatments. Brawley (2011) has advocated for men to be informed about all the risks and benefits of being screened for prostate cancer. He pushes for firm evidenced-based guidelines that are backed by science. He suggests that without evidenced-based guidelines backed by science, that guidelines are merely causing harm to patients (Brawley ; Goldberg, 2011).
Dr. Brawley’s book is relevant to healthcare today. In his book, he talks about unnecessary treatments, wallet biopsies, and the need for better healthcare in America (Brawley & Goldberg, 2011). Unnecessary treatments happen daily to millions of patients, and it is ultimately causing harm as well as increasing the cost of healthcare. Wallet biopsies happen today to people that need treatment for their cancer or disease but are unable to receive any due to not being able to pay for the treatments. Stronger evidence-based guidelines backed by science are needed to guide Americans on the appropriate time to have screenings done. Overall, a change needs to come forth in healthcare for America. Brawley mentions that before this can take effect, the American people are going to have to distinguish between science-based medicine and medicine of self-interest
Brawley, O., & Goldberg, P. (2011). How we do harm: A doctor breaks ranks about being sick in America. New York, NY : St. Martin’s Press.
Carroll, A. (2017). The high costs of unnecessary care. JAMA, 318(18), 1748-1749. http://dx.doi.org/10.1001/jama.2017.16193
Delgado, M., Yokell, M., Staudenmayer, K., Spain, D., Hernandez-Boussard, T., ; Wang, N. (2014). Factors associated with the disposition of severely injured patients initially seen at non-trauma center emergency departments: Disparities by insurance status. JAMA Surgery, 149(5), 422-430. http://dx.doi.org/10.1001/jamasurg.2013.4398
Duncan, S., Thorne, S., ; Rodney, P. (2014). Evolving trends in nurse regulation: What are the policy impacts for nursing’s social mandate? Nursing Inquiry , 22(1), 27-38. http://dx.doi.org/10.1111/nin.12087
Grimm, K., & Saini, V. (2015, October 21). What right care means to me: The physician’s view Blog post. Retrieved from https://www.rwjf.org/en/blog/2015/10/what_right_care_mean.html
Karnik, S., ; Kanekar, A. (2016). Ethical issues surrounding end-of-life care: A narrative review. Healthcare, 4(2), 24. http://dx.doi.org/10.3390/healthcare4020024
Salmond, S., ; Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic Nursing, 36(1), 12-25. http://dx.doi.org/10.1097/NOR.0000000000000308