Center Assistant Professor Jennifer McCurdy, PhD, BSN, MH, HEC-C, presented “Beyond Patient Behavior: Using Structural Competency to Create Health Equity” at the Michigan State Medical Society (MSMS) 26th Annual Conference on Bioethics: Contemporary Challenges in Clinical Bioethics in November. McCurdy’s presentation explored the social, political, and economic contexts that act as barriers to patients care and impede physicians’ ability to effectively treat them.
McCurdy asked those in attendance the following questions: Have you ever experienced moral distress or frustration associated with the medical “system?” Have you ever been unable to treat a patient for whom treatment exists, based on factors that are out of your control? What were those factors?
Using a case example, McCurdy discussed factors that determine the health status of an individual, such as behaviors, cultural norms, and biology. She also discussed social determinants of health, such as poverty, inadequate or no housing, lack of access to education, and lack of access to healthcare. McCurdy also outlined structural determinants of health, pointing to social structures, political structures and policy, and economic structures and policy—the “causes of the causes.”
How can physicians help? They are uniquely positioned in spaces that connect the medical world and the patients’ worlds, where they can observe recurrent barriers to care. They can work to create change at individual, interpersonal, and institutional levels. McCurdy also outlined how physicians’ involvement in the community, in policy, and in research can create structural change and therefore improve health equity.
- Neff J, Holmes SM, Knight KR, Strong S, Thompson-Lastad A, McGuinness C, Duncan L, Saxena N, Harvey MJ, Langford A, Carey-Simms KL, Minahan SN, Satterwhite S, Ruppel C, Lee S, Walkover L, De Avila J, Lewis B, Matthews J, Nelson N. Structural Competency: Curriculum for Medical Students, Residents, and Interprofessional Teams on the Structural Factors That Produce Health Disparities. MedEdPORTAL. 2020 Mar 13;16:10888. doi: 10.15766/mep_2374-8265.10888. PMID: 32342010; PMCID: PMC7182045.
- Gruen RL, Campbell EG, Blumenthal D. Public roles of US physicians: community participation, political involvement, and collective advocacy. JAMA. 2006 Nov 22;296(20):2467-75. doi: 10.1001/jama.296.20.2467. PMID: 17119143.
By Liz McDaniel
On November 11, Center Assistant Professor Dr. Devan Stahl presented at the Michigan State Medical Society 21st Annual Conference on Bioethics. Held in Ann Arbor, the conference’s theme was “First do no harm: Avoiding Overdiagnosis and Overtreatment in Medicine.” Dr. Stahl gave the talk “Responding to those who Hope for a Miracle.”
Dr. Stahl presented strategies for engaging patients and families who request aggressive care with the hope of obtaining a “miracle.” As discussed in her latest article*, Dr. Stahl laid out a taxonomy of how the term “miracle” is used in the context of health care, as well as tips for healthcare providers responding to those particular invocations. The audience was presented with case studies that highlighted the different ways in which a patient may use miracle language as well as communication strategies that can help further a dialogue about appropriate and inappropriate uses of medical treatments.
* Note: viewing this article may require MSU Library or other institutional access.
Center Professor Dr. Len Fleck presented at the 20th Annual Michigan State Medical Society Conference on Bioethics, held on November 12, 2016 in Ann Arbor. The theme of the conference was “Ethical Issues in the Pharmaceutical Industry: Current Controversies and Challenges.” Dr. Fleck’s presentation was titled “Curing Hepatitis C: Whose Cost? Whose Responsibility?” Dr. Fleck discussed several ethical and policy issues around the drug Sofosbuvir, otherwise known as the $1000 pill. This is a drug that requires 12 weeks of treatment at a cost of about $100,000.
There are about 3.2 million Americans who are Hepatitis C (HCV) -positive. About 30% of those individuals do not know they are HCV-positive. Unlike most drugs on the market today, this drug is actually curative for up to 95% of patients treated. But the cost of treating all Americans who are HCV-positive at current prices would be $300 billion.
About 800,000 HCV-positive individuals are covered by Medicaid. No Medicaid program can afford to provide this drug to all HCV patients without a massive shifting of resources that would be neither just nor justified. The relevant medical facts are that HCV could result in life-threatening liver problems for as many as 70% of these patients, but these outcomes would typically be ten to thirty years after infection (if ever). Many of these individuals will die of something else, which is one reason why Medicaid wants to avoid paying to treat these individuals. Also, the Medicaid population “churns” a lot from year to year, primarily because many individuals are successful in getting jobs and getting out of poverty. Consequently, someone else would become responsible for paying for the drug (if they have a job with employer-sponsored insurance). To limit costs most Medicaid programs require recipients of the drug to have advanced liver fibrosis, Stage F3 or F4. This is ethically problematic because Sofosbuvir will cure their HCV but not stop disease progression. Consequently, 7% of F3 patients will die of complications of liver disease and 22% of F4 patients will suffer that fate. This is not at all ethically or medically congruent with the way heart disease or cancer or other chronic degenerative conditions would be treated in these patients.
Dr. Fleck concluded three things: (1) The price of Sofosbuvir is unconscionable; there is no ethical or economic justification for that price. (2) Medicaid programs would be on sounder ethical ground if treatment were initiated no later than F2 where 3% of patients would still die of liver complications. (3) The deeper source of the ethical issues in this case is the fragmentation of the American system for financing access to needed and effective health care. That fragmentation encourages the diffusion and disavowal of responsibility for meeting the health care needs of these patients.
The Michigan State Medical Society 18th Annual Conference on Bioethics was held on November 7-8, 2014 in Ann Arbor, MI. The conference featured presentations from Center Director Tom Tomlinson and Center Professor Leonard Fleck.
Just Palliate: Is Comfort Care Cut-Rate Rationing?
Leonard M. Fleck, PhD, Professor, Center for Ethics and Humanities in the Life Sciences, Department of Philosophy
Ethical Obstacles to Timely Palliative Care in Oncology
Tom Tomlinson, PhD, Director, Center for Ethics and Humanities in the Life Sciences; Professor, Department of Philosophy
Read more about the Michigan State Medical Society.
Akshay Srikanth presented the following poster at the Annual Meeting of the Michigan State Medical Society, which was held October 23-25, 2013 in Troy, MI.
“Evaluation of the use of a decision aid during diagnosis visits in early stage prostate cancer.”
Poster by Srikanth A, Kahn VC, Rovner DR, Greenwell A, Ellsworth E, Harder M, Holmes-Rovner M.
This poster evaluated the relevance of an informational decision aid during diagnosis visits in early state prostate cancer by using tape-recorded clinical encounters. Results show that a decision aid is significant during diagnosis visits through the number of times it was referenced by both the patient and physician. Additionally results show the decision aid was referenced most often in the context of treatment options and was used most often to learn more or validate something during the discussion. A decision aid can be used in cases of early stage prostate cancer to help patients make a more informed decision and may facilitate during the shared decision making process.
Akshay Srikanth is a second year College of Human Medicine student. He is working with Center faculty member Margaret Holmes-Rovner on an ongoing AHRQ (Agency for Healthcare Research and Quality) funded research project titled “Clinical Communication Following a Decision Aid.”
Leonard Fleck, Professor in the Center for Ethics and the Department of Philosophy at MSU, will be speaking at the 16th Annual Conference on Bioethics, hosted by the Michigan State Medical Society September 21-22 at the Campus Inn in Ann Arbor, Michigan.
The conference, Will the Patient-Physician Relationship Survive? will explore the growing threats to the doctor-patient relationship subsequent to ongoing economic, political, regulatory, and technological transformations in health care.
Dr. Fleck’s lecture, Parsimonious Care: Does Ockham’s Laser Belong in Medicine’s Black Bag? will take place on the second day of the conference.
For more information or to register, visit the Michigan State Medical Society’s website.