Oregon has had government involved in health care for quite a few years.  The state electorate also approved the concept of state sanctioned suicide several years ago.

Recently, the board that reviews the medications that are approved for state residents made a determination that was controversial...in my mind if no where else.  The board, in essence, said that, given the cost of a certain medication, it would approve suicide for this patient but would not approve use of the medicine given its relative newness and the lack of convincing data as to the outcome.  It had essentially set a price on the human life involved.

Today I read the story concerning Denver Children's Hospital and heart transplants in infants that use the heart from another infant that died a 'cardiac-related death'.  This differs from a heart harvested from a brain-dead infant in which that heart is beating until removed from the donor body.  A decision has been made that the donor that has been pronounced dead and has been in that state for only 75 seconds, is a valid heart donor for purposes of this new program.  The earlier line that had existed required death be determined only after some five minutes during which time the heart did not re-start itself.  In this instance, the length of time a person had been deemed 'dead' had been reduced to assure that the harvested heart had a decent chance of functioning in the new body.  The three cases in which this approach has been employed resulted in three infants alive today.  The decisions to withdraw life support were made by the parents in all three instances.

We know so much more today than we did a decade ago.  We can do things from a medical perspective that were impossible then, and these procedures have become commonplace now.  We are, in this area, pushing the envelope as it has never before been pushed.

I know there are at least two sides to these issues.  I have good friends whose daughter lives today because of transplanted organs that were available on a timely basis.  I can't even begin to comprehend being placed in the middle of such decisions, and I earnestly hope that never befalls me.

And this leads to my general question:  Is there a line we dare not cross?  If so, where is or was that line?  Am I comfortable with an appointed board making life and death decisions about me?  Who among us can claim the right to make such a decision?  How do medical ethicists deal with these kinds of issues?

I don't profess to have the answers to these questions.  If you do, and you're willing to share, I'd appreciate your comments.

I've written about the consolidation of local health care organizations over the past months.  In preparing for a talk I delivered to an insurance agent's organization last month, I dug a little deeper to see what the trends seemed to be for the future.

There are some very interesting things happening to and with health care delivery and these things are, in part, already on or affecting the local scene.

Retail Medicine...

Several major corporations have experimented with and made commitments to what I'll call 'retail medicine'.  Major drug store chains have had walk-in clinics in their stores, and have gotten so serious about it that they've actually purchased the companies that were supplying the services.  One of those is Walgreen's and we see the result in Germantown.  Our local Walgreen store is 1 of 13 in Wisconsin with in-store clinics and that number is expected to be as high as 19 by the end of 2008.

Wal-Mart is doing similar development across the country along with the CVS drug store chain and several others.  These models all tend to rely upon the Nurse Practitioner and work to establish referral relationships to local physicians for the more serious conditions encountered.  Costs, according to the Take Care Health Systems (Walgreen) website range from $59 to $74 per visit with additional fees charged for vaccinations (seasonal flu shot priced at $24.99).

Physician Shortages... 

There are serious shortages of physicians in America and that is, in part, prompting the 'retail medicine' movement discussed above.  Massachusetts learned this the hard way when it passed laws that required virtually all citizens to have health insurance.  There were simply too few primary care doctors available in the state to handle the new demand that had been created.  The physicians who are moving through the education system today are too often choosing specialties that pay more and that have better schedules so they can also spend time with their families and pay off their loans more quickly.

These shortages are prompting our medical colleges to step up the effort to cause more graduating physicians to opt for primary care service but this will take time and there will need to be some economic push to make it happen.  This is spawning the following effort.

Nurse Doctors...

Minnesota has graduated at least one class of Nurse Doctors who are entering practice across that state.  This is a doctorate level program that claims to produce practitioners that "can do almost everything" a primary care physician can do except for some surgical procedures.  This program is being expanded to be able to graduate more Nurse Doctors every year as the program ramps up.

As we can all understand, the physicians' organizations are not at all happy about this movement.

Dentist Shortages...

The average age of dentists in many states, Wisconsin included, is increasing at an alarming pace and we are beginning to see a shortage of dentists.  Minnesota again seems to have taken a lead position with legislation that was being considered which would permit Dental Hygienists to both drill and extract teeth in addition to their normal responsibilities.

As you would also expect in this situation, this is meeting strong resistance from the organizations representing dentists, but the simple fact that this found its way to the floor of the Minnesota legislature is significant.  Minnesota has been more prone to experimentation in the general area of health care (health maintenance organizations took off very rapidly in this state in the early-1970s), so these trends aren't all that surprising in our neighbor state.

Summary...

Our health care world is changing very rapidly.  If we were to become a Rip Van Winkle and sleep for even just ten years, we'd likely encounter a strange new health care world when we awoke.

Who can say what is good or not good in these regards.  Time will tell which, if any, of these initiatives we will have accepted and which we will have discarded as bad ideas whose time hadn't yet arrived.  Some way needs be found that will permit us to control costs.  If we rely upon government to do that, I'm afraid that the consequences will be heavy-handed control and rationing of services...and I cannot find it within myself to think that is an improvement.

The New England Journal of Medicine, yesterday, published results of a study on prostate cancer and the various treatment regimens employed.  I selected this as today's topic since I'm a man, I've had friends who've died from the disease, I have friends who now have the disease, I'm in the target age group and fully one in six males will be diagnosed with prostate cancer.

Prostate cancer is the most common form of cancer in men and the number two killer second only to lung cancer according to the American Cancer Society.  It is predicted that there will be some 186,000 diagnoses this year and some 28,700 deaths are expected from the disease.

The New England Journal of Medicine reported on the study of a group of 1,201 men and their partners after three kinds of treatment had been administered.  Those were: removal of the prostate; implantation of radioactive 'seeds'; and, radiation therapy.  Of the group who had received either radioactive 'seeds' or radiation therapy, one-third also took hormones.  The Journal was careful to note that the patients and doctors had made decisions independent of this study so the conclusions drawn were said to be suggestive rather than conclusive.

The conclusion drawn by the urologist who led this study, Dr. Martin Sanda of Beth Israel Deaconess Medical Center in Boston, was this (as he was quoted saying): "Doctors or their patients should think twice if they're considering hormone therapy.  Most of the cancers treated nowadays are not really that aggressive."

The good news is that more than 99% of patients survive at least five years.  Thirty years ago, only about two-thirds survived that long.

This study showed that too much treatment can make a patient needlessly miserable. Complaints with hormone therapy centered on lack of sexual drive, problems with urination and bowel problems.

I remember very well my conversations with my friend John, of whom I've written before.  He was adamant that the quality of his life was more the issue than the length of his life.  He was encouraged to take hormone therapy and refused to do so after reading of the possible side effects.  He knew that was the right decision for him and maintained his quality of life until very near the end.

What lesson can we all draw from this?  I think the most important lesson is this:  Men should not avoid being examined for prostate enlargement and PSA counts for fear of what might be detected.  That is a very, very small price to pay for the peace of mind that flows for most of us as the result.  And, early detection is by far and away better for the patient because treatment can be begun before the cancer has grown too large to control.

The rule of thumb that I've always heard was that we men should begin to be examined for prostate issues at age 50.  My  feeling is that even earlier would be better.  My friend was diagnosed at about his age fifty and the cancer had already gotten a good start by that time.