Addressing the Social Antecedents of Health Problems and End-of-Life Issues

By: Linda Harder

Photography by: Tracey Brown

An Interview With Delegate Dan Morhaim, M.D.

As part of our ongoing interviews with key Maryland policy makers that spotlight initiatives impacting physicians, Maryland Physician recently sat down with the only physician in the 188-member General Assembly. His views on addressing common health problems and their social causes follow.

What led you to become a politician?

There were so many things I saw as a career emergency physician – first as Chairman of Emergency Medicine at Franklin Square for 14 years while building a six-hospital group practice. When I got elected to the legislature in 1994, I moved over to Sinai Hospital, a level-2 trauma center.  So many of the cases I was seeing had social antecedents – such as diabetes and preventable trauma. Emergency rooms admit about 70% of patients seen in the hospital, so it’s a focal point. I kept seeing patients with problems that could have been better dealt with beforehand. There are underlying causes for many of our health problems that should be managed before coming to a crisis.

In the early 90s, I attending community meetings and asking why we didn’t have curbside recycling. The end result was that I was appointed to the city/county task force on recycling. We designed a system that would work, and now we have recycling in Baltimore County and City. It gave me a sense that governing is hard work and requires attention to details, but that it makes a difference. That experience – and wanting to raise my three children in a world that was healthy and safe – contributed to my decision to run for office.

How did being an ER doctor influence you?

As an ER doctor, you get a direct and immediate indication of what’s going on in the community, and you take care of every kind of person.  That requires learning to deal with everyone from a rich person to a drug addict to a young child, as well as the other health providers involved in care delivery.

I finally stopped doing emergency medicine about three or four years ago. I calculated that I had not slept at night for 30 days in a row from 1974 to 2007. Over the years, I’ve treated about 170,000 patients.

The last three years I worked at Healthcare for the Homeless, and now I’m on their board. And 12 years ago, I joined the faculty of Hopkins Bloomberg School of Public Health, where I do teaching and research. One of the papers I wrote was the data substrate for my book, The Better End: Surviving (and Dying) on Your Own Terms in Today’s Modern Medical World (Hopkins Press, www.thebetterend.com).

What are the most significant end of life issues physicians should be aware of? What’s your message to them?

We are not comfortable talking about end-of-life care, but the more we do, the more comfortable we’ll be. We have a strong cultural and medical taboo against talking about death and dying, but we’re the first generation that likely has a say in how, when, and where we die.  The good news is that technology has helped us live longer, healthier lives. The challenge is that, if you have widespread metastatic cancer, do you really want to end up in an ICU in your last days?

There are free legal documents – advance directives  – that have been around about 20 years. We did a study at Hopkins and found that only about a third of Americans have advance directives.

A lot of emergency medicine has become geriatric. I found myself doing things to patients in the name of care that is not care. A 95 year old comes in from a nursing home in extremis, and the ER staff jumps to full CPR mode, and that person may survive a few hours or days.  In a culture that values individual rights and freedom so much, patients’ can and should have a role in making these decisions.  Completing an advance directive doesn’t mean a diminution of care. It’s care according to your wishes and values. But we collectively abdicate on this issue.  It’s important to empower people because we can influence this process that we’re all going to confront.  And our study showed the people want to discuss this with their physician.

End-of-life care costs a lot of money. About 30% of Medicare expenses are for end of life care, and expenses are considerable for Medicaid and commercial insurance as well. Presumably if the rate of advance directives went up, more people would choose less intense care and less money would be spent.  But we’d be spending less money the right way – through individual decision-making. Technology can serve us, but it can also separate us from the process of death and dying. This all starts with the individual filling out the forms. Only you can do the paperwork.

Describe some of the legislation you’ve been involved with.

A lot of my political actions were informed by my emergency medicine experience. For example, the worst night of my life was seeing three children killed in a drunk driving accident, and so I’ve been involved with bills related to drunk driving.

I’ve worked on expanding and improving addiction treatment programs and legislation on the issues of advance directives and end of life care.  I’ve done a lot of health care bills, with a focus on helping patients and supporting providers. At this point in my legislative career, I often choose to work on others’ bills and don’t feel the need to be the lead legislator as often.

I also work to streamline government operations, saving money through consolidation and efficiency. I’ve also worked on numerous bills promoting the environment, education, jobs, and public safety.

Tell us about your peer-review legislation

When I started years ago there wasn’t any particular orientation to peer review. When I was in emergency care, I evolved with my colleagues to a reasonably good system, but it wasn’t as well structured or as valuable as it could have been. It’s an important part of healthcare.  It’s not just pushing papers around. It actually has to have integrity and value in improving the quality of care.  But even the simplest things in healthcare are complicated – treating a sore throat, for example: you have to at a glance evaluate the tonsils, look for exudate, dentition, other conditions, etc. Evidence-based medicine is a good thing but can be challenging to translate into practice.

I try to remind everyone that healthcare is still delivered by people one-on-one. It’s not the hospital that starts the IV – it’s a nurse, physician assistant, or paramedic. The insurance company doesn’t reduce a dislocated shoulder – it’s me. It’s easy to stand on the outside and make comments, but it’s a lot harder on the inside making the decisions.

Tort reform continues to be a major legislative focus in Maryland. What are your views on this subject?

The macro issue is that first, going back to peer review, you really want to do the best you can – have quality and consistency – before a problem arises. Tort deals with issues after they’ve happened.  Second, you want to involve patients and families when bad things happen. A lot of times, people just want to know that they’ve been heard and that their problem is acknowleged. You want to quickly take care of an incompetent doctor, but many times, it’s no one’s fault. Going through a long series of legal cases ends up being a random lottery as to who wins, and often doesn’t help the patient.

The solutions can include mediation, no-fault, open discussions when things don’t go well, and aggressively addressing systemic problems. The tort system we’re currently using is cumbersome, expensive, and rarely fair or helpful.

Gun control – do you think it will pass and what is your position?

I think it will pass, and I’m pretty sure I’ll support it. However, what you really want to do is prevent murders before they happen. The bulk of murders can be traced back to several things.

Most shootings are related to drugs. What does it cost to maintain a habit in this area? It’s $25 to $50 per day. If you multiply that by 75,000 addicts, you get to billions of dollars. Some incorrigibles need to be locked up, but I’m strongly for addiction treatment programs. People do have relapses, as they do for any medical condition, but if you get someone in an addiction program today, at least they’re not committing a crime that day. Over time, most can be rehabilitated. I support medical marijuana, which is another topic.

Second, most people who kill each other know each other, despite the occasional horrible exceptions like Aurora or Newtown.  Domestic violence issues can be dealt with through more aggressive restraining orders, limiting gun access to those who have been identified as having problems, and so on.

Third, there are the mentally ill who are dangerous. Most mentally ill people are not dangerous, and most dangerous people are not mentally ill, but there is overlap. Having done mental health assessments in the ER, sometimes you can tell who is at high risk. For example, patients who have a history of hurting animals or setting fires are at very high risk for violent behaviors. Generally our mental health system needs to improve for regular kinds of mental health problems.

Last, we need to greatly improve our juvenile justice system. Too many youngsters are not rehabilitated there, and they need all the help they can get to get on the right track in life.

Then, you get to the gun issue. I’m in favor of more restrictions on assault weapons and background checks, but we need to talk about the other issues that lead to violence in the first place.

At Healthcare for the Homeless, I’ve seen a lot of men who have committed crimes. Some say, “I did a three-spot” (served three years in jail) as casually as if they were saying they went to the movies last night. I’ve had patients tell me about cold-blooded murders they did. One man said he was 15 when he was in for ten years. He had killed six people as a young kid. The drug dealers would give him two thousand dollars and a gun and have him walk over and kill someone. He did that five or six times and then he got caught.

There are others issues as well that lead to terrible crimes, such as elder abuse to human trafficking. So, legislatively, it goes back working on underlying social antecedents.

What other legislative initiatives are you involved with?

I work on many issues as Chair of the Government Operations Subcommittee of the Committee on Healthcare and Government Operations. There, we work to identify efficiencies that will save money without having to raise taxes or cut programs. We also promote programs to help minority, women, small, and veteran owned businesses.

I’ve focused on transparency and competition for government contracts, and that has saved millions of dollars.  I’m filing a bill to improve our open meetings statute to help ensure greater public participation.

We have a serious shortage of certain medications. Generic drugs – primarily sterile injectables – are becoming increasingly unavailable. Hospitals are having trouble finding epinephrine, sodium bicarbonate, atropine, propofol, and other commonly used medicines.  Much of the problem is at the federal level, but I’m working on what we can do in Maryland.

 Dr. Morhaim’s book can be found at www.thebetterend.com or at Amazon.

 


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5 Comments

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