The best-known proponent of sustainable medicine is probably Daniel Callahan, Ph.D., Professor at Harvard and Yale Medical Schools, and Director of International Programs at the Hastings Center. Through his writings, lectures and conferences, Callahan confronts the underlying orthodoxy of the medical establishment, showing how the relentless pursuit of medical progress is actually itself at the very core of today’s health care crisis.
Callahan is a tireless crusader for a fundamental reorientation of the goals and priorities of our public health care system. But while public policy is one thing, a medical practice is quite another. Here, thousands of individual decisions are made, all with the patients' best interests as our priority. So while many of Callahan's ideas are very important, it will require practicing physicians to negotiate the potential conflicts between quality care and sustainability.
At the Kimberton Clinic we are attempting to develop this pioneering work. Here, sustainable medicine rests on the following principles:
- Medicine must be economically sustainable. This means there must be some attempt to control costs in a way commensurate with quality medical care. Just as we all have an individual moral duty to reduce environmental pollution and global warming, so must we all be committed to cost containment, regardless of what kind of medical insurance we do or do not have. The good news is that appropriate cost containment should lead to better, not worse medical care. How can this be? Because indiscriminate tests and imaging studies frequently increase rather than reduce a patient's risk. Here are but two examples: A CT of the abdomen is ordered for a patient who most likely has an intestinal virus. It is read as normal except for the incidental finding of a growth on the liver, clearly unrelated to the current symptoms. Although it is theoretically possible that a malignancy has been accidentally discovered, the overwhelming likelihood is that the patient will be subjected to expensive, painful and sometimes dangerous procedures, only to be told that " it was nothing." A doctor orders a lyme disease test in a situation where a careful history would show that the patient's symptoms are not consistent with that diagnosis. The test comes back equivocal (as they often do) and the doctor, not wanting to miss anything, elects to treat with antibiotics. The patient, now convinced that he or she has lyme disease, does not improve with the first course of antibiotics, and ends up being treated for months or even years with antibiotics for a "disease" they never had.
- A sustainable medicine must strive towards the long-term goal of maximizing health. Overuse of antibiotics, pain medicines and psychopharmacological drugs, for example, is not consistent with this goal. Emphasis on healthy nutrition, exercise, personal fulfillment, spiritual balance and other lifestyle issues, are integral to it.
- A sustainable medicine requires a sustainable doctor-patient relationship. Impersonal medical care from large groups and emergency facilities is incredibly wasteful, and unsatisfying for doctor and patient alike. Groups should be small, locally-owned, and if possible, socially embedded in the community. The doctor should live near his or her patients and be seen in non-medical situations – at little league games, school events, at the food market and cultural events. The practice must strive to enhance long-term doctor-patient relationships, where patients know who their doctor is, even if he or she is in a group. When a trust relationship is built up, there are fewer unnecessary trips to the emergency room, fewer CMA (cover-my-behind) tests run, and an atmosphere is established where the fear of lawsuits is not a major (or the major) determinant of decision-making.
- It has been estimated that the average American spends 50% of his or her lifetime medical costs during the last few months of life. Yet so many people in America die a lonely, miserable death, in a sterile, unfamiliar environment, surrounded by machines rather than loved ones. A sustainable medicine must bring end-of-life decisions back to a trusted doctor/patient/family relationship.
- Sustainable medicine has been critically characterized as asking people to die cheaply or to deny themselves worthwhile advances in medical science. This is absurd and unfair. Our goal is better, not worse medical care, for the individual as well as society, both now and into the future.
