we haven’t yet made one person im- mortal. At some point in time, more disease treatment does not equate to better care. So we have to broaden our perspective. I’ve come to believe that the secret sauce in providing the best care I possibly can to each and every person is called shared decisionmak- ing. I was born in 1951, and growing up, medical shared decisionmaking happened when the doctor shared his decision with you. It’s no longer that. Nowadays, we recognize that patients come to the doctor-patient relation- ship already expert in their values, preferences, and priorities. And we doctors are experts in the diagnostics and therapeutics of their condition. Together, in shared fashion, we can apply the best medical science and technology consistent with the values, preferences, and priorities of each person in service of achievable goals of health care. And the fact of mortal- ity is a legitimate backdrop for having conversations about life-prolonging treatment.
Texas Medicine: Is this the domain of just palliative care specialists or all physicians?
Dr. Byock: If you think your patients are too young, or too healthy, or you’re just a specialist, I beg to differ. At least 70 percent of practicing physicians participate in the care of frail elders or seriously ill people whose lives are at serious risk. Obstetricians and gyne- cologists tell me they don’t ask about advance directives because, after all, the women they care for are young and healthy. So was Karen Ann Quin- lan. So was Nancy Cruzan. So was Terri Schiavo. I know, having prac- ticed emergency medicine for years, and now palliative care, that some- times young, healthy people become suddenly seriously ill. In my world, it’s not even uncommon. They ought to have a chance to have spoken for themselves, at least in naming some- one they trust to speak for them, but also in expressing their values. When
PHOTO PROVIDED BY TRISHA SHANDS, MD
ADVENTURES IN ALASKAN MEDICINE
TexMed keynote speaker Trisha Shands, MD, prac- ticed in the Seattle area for 10 years before mus- tering the courage to fol- low her lifelong passion to help the underserved and underprivileged full time in Alaska. In 2007,
Dr. Shands, an orthopedic surgeon and Texas native, became chair of the Department of Orthopedics at the Alaskan Native Medical Center in Anchorage. Dr. Shands’ job is to travel to 13 regional field clinics around
Alaska because travel logistics for patients in remote areas of the rugged state often pose barriers to care. “The patients I take care of live in a village of 200 people. Many of them still maintain a subsistence lifestyle living off of the land. Depend- ing on where they live, they would have to travel via river, or snow machine if it’s winter. A few of them even dog sled.” The patients she sees now also differ vastly from the mostly
healthy, active, young professionals she treated in Seattle. “We see a lot more trauma, just because of the nature of the lifestyle here: snow machines, four-wheelers, mixing firearms and alcohol. Bear attacks are not uncommon. It’s rough living in Alaska. It’s a hard place.” But Dr. Shands does not regret her decision one bit. “When I left my practice, I wasn’t worried my patients would not get good health care. But here, it’s hard to attract provid- ers. Patients aren’t always covered. And that’s what attracted me to it: the opportunity to take care of a population that doesn’t always get good coverage,” she said. “Sometimes we have a routine and a way of practicing medicine, and when you step outside of that, you realize this is a unique form of health care I don’t know of anywhere else. I want to be able to share how we do that, and the challenge, and the adventure, and reward of being able to do that.”
April 2015 TEXAS MEDICINE 59
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