malaysiakini: Good doctors are good communicators... by Dr S

Good doctors are good communicators

Dr S
malaysiakini, Sep 14, 10
4:52pm

 

I am writing to 'AM" in response to his/her letter Taiping Hospital snuffed out my father's life. 

Firstly my condolences to you and your family on the loss of your father. I have taken some hours to write this reply to hopefully make you feel a little better by shedding some light on the reasons behind some of the actions by the doctors who treated your father. I would also like to shed some light on possibly what could have been improved on and hopefully relieve some of the negative sentiment towards Malaysian hospitals and doctors despite me not being affiliated to any of them.

My name is Dr S, a Malaysian, and I graduated and currently work in the UK for the National Health Service. I will pitch my letter for everyone including non-medics and try not to use very technical terms or to simplify any that I use. From the story you have related, and my experience working in General Medicine, Old Age Medicine, the Emergency Department, and other critical departments, I gather that your father suffered (in simple words) a large heart attack, and as a result had rapidly progressive heart failure.

Such an occurrence in a 94-year-old is almost always not remedial no matter what is done, especially if the bulk of his heart muscle tissue is no longer functioning due to the heart attack. If at all there was any possibility of active treatment of his heart attack, it would have been early thrombolysis (administration of medication to dissolve the clot that was causing his heart attack) with the hope that the heart muscles that were starved of oxygen were not totally dead, which happens pretty quickly. Thrombolysis is not always possible, as there strict criteria and many contraindications (things that would make him unsuitable for it).

Based on what the doctors at the Taiping hospital told your relatives at the emergency department (that he had a heart attack, and that his heart was weak) and the classical sequence of events on his condition, it seems to me that they conducted the relevant tests, did the relevant examination, and concluded that he had a heart attack and a resultant heart failure very early on. The diagnosis of an acute coronary syndrome is not inaccurate, as it is a broad umbrella of a number of conditions where the heart is/was starved off oxygen, which includes what your dad had - which is likely to have been a heart attack.

In someone who is 94, even if he was quite fit and able otherwise, if it was even a slightly delayed presentation with no chance of busting the clot (thrombolysis), CCU and ICU would not be the right thing to do. ICU in simple words would be for those who need full-time monitoring and treatment for an acute problem that is very likely to be remediable (not the case in your dad unfortunately), and CCU for those who need active constant cardiac monitoring due to the potential need of immediate cardiac intervention usually signaled by cardiac arrhythmias (irregular beating of the heart) or monitoring after recent intervention which could cause arrhythmias (like if your dad was thrombolysed).

Admitting him to a standard ward was thus the most appropriate place for your dad from a medical point of view, and if your dad had the same problem in the UK under the exact same circumstances (with the assumptions I have made) - it is exactly what would have happened. Inotropes is not something I would have given and was not going to be the appropriate treatment for him at any point in time unfortunately. I am guessing that the CCU and ICU option which you were very keen on may have been standard practice in the past when you were practicing hospital general medicine which I assume you no longer do.

Touching on his diet - I don't know what his swallowing ability was like on admission. If his swallowing was assessed and it was thought that it would be safe for him to have a solid diet - I see no contraindications for him to have enjoyed whatever food he wished for during his last days. If he had problems swallowing food safely, then a suitable diet would have needed to be considered further. A heart attack and/or a chest infection on its own or even in combination is not a contraindication for a normal diet.

I see many patients who are 94 or older, and in all cases, it is vital for doctors to make rational decisions on medical management which take into account not just the patients age, but also underlying diseases and pre-hospital quality of life (ie. self caring, self-feeding, self-cooking, mobility, etc). It seems to me that the doctor did tell your sister what your dad was suffering from and that your relatives needed to be informed, which was correct, but perhaps a more polite approach and further explanation on exactly what he had and why it was not reversible, why CCU and ICU was not an option, and why she had to tell your relatives sooner rather than later would have helped clarify things.

Communication is key - and it is something very, very strongly emphasized on in the UK health system and health education, and I think can be improved on significantly in Malaysia. I have had to tell patients relatives on many occasions that their father/mother/brother/sister/friend/son had days/hours to live, what exactly was wrong, what the management plan was, and why it was not curable, and it has always worked in keeping relatives calm, in the know, and making them feel part of the team looking after their loved ones.

A drip being absent in your fathers case is a good sign. If he had a drip with fluids running through, I assure you it would have accelerated his death and you may not have made it in time to see him alive. What could have possibly helped his breathing would be some diuretics to get rid of the excess fluid, however this would only prolong his life very marginally, as his kidneys would have likely been on the verge of not functioning at that point. Moving your father to any other ward during his final moments would not have brought your father back to how he was before he was ill - not even close to how he was.

We try very, very hard not to move elderly patients who are clearly at their final days or moments in life as it disorientates and distresses them and confuses all those looking after them creating room for errors, and does not change the final outcome in any way. An emergency trolley, CPR, and intubation again are out of the question, as it would not have changed the final outcome, and at best it would have given him many broken ribs only to die in pain and possibly choking. I am glad it was not attempted and would have been a serious error in judgment if it did.

The doctors could have however come to your aid sooner, but the aim would have been to explain things to you more clearly and ensure your dad was kept comfortable by means of palliative medication rather than to attempt any heroic measures. I take it that your dad was not very alert/responsive when the doctor arrived hence why they shone the light in his eyes - which is the correct thing to do. That the doctor denied your request for him to be intubated was neither pride nor ego but was likely to have been the correct medical decision, as it would have at the very best made things worse.

Touching on the issue on the time of death, it is acceptable for the doctor to record the time of death to be the time at which he pronounced him dead or the time at which another treating health professional saw him lifeless. Even if there was pretentious resuscitation by the doctor for 20 minutes, if the doctor felt that all this was only stopped at 20:17 and at that moment examined him to find no signs of life - it is correct for him to have recorded the time of death to be 20:17. To give you an example of an unrelated situation, if a nurse finds a patient lifeless at 6am, and calls the doctor to pronounce him dead, the time of death will be 6am even if the nurse thinks the patient had passed away at least five hours before being found.

The doctor can even chose to write down 06:30am if that's when he arrives to see the patient, and he is not confident that the nurse made adequate assessments at 6am to be absolutely sure that the patient was dead at 6am. This is not uncommon especially for deaths through the night when the exact time is often not known.

In your father's case, particularly when he was beginning to be breathless and distressed and was clearly near the end, what should have been initiated was a morphine, midazolam, and hyoscine continuous infusion just under the skin, with doses of each drug dependent on what exactly was the distressing issues. At one of the hospitals where I practiced, we used what is called the Liverpool Care Pathway which is a very good guidance and checklist on the management of patients at their final moments of life (which can be up to days or weeks even).

You could hopefully Google it, and I think it should be widely implemented in Malaysia if not already so. On the issue of a post-mortem, this I'm afraid I cannot comment much on as policies can vary greatly from place to place for different reasons.

Finally it is sad to see many respondents attacking the medical conduct of the doctors involved in this situation as well as attacking the practice of medicine in Malaysia, particularly the government hospitals. I will not make comparisons to the UK health system due to my current position and obligations, but I have to say that Malaysians should thank the government many times over for the standard of healthcare they receive. Some may ask why I am in the UK and have not returned to Malaysia - the reasons are personal, and is unrelated to the quality of Malaysian health care in any way.

I cannot find much fault in the medical care of your father in terms of which ward he was in, what he was allowed to eat, that he did not have a drip with fluids running, was not given inotropes, not intubated, not in CCU or ICU, and not actively resuscitated - which were all the right treatment measures. Again, I emphasize that communication is often key, and poor communication is often the cause of many misunderstandings and unhappiness, and can make a big difference in a patients management.

The most successful doctors and consultants I have come across have not been the smartest and most knowledgeable, but are often the best communicators, and I hope all doctors who are reading this, even if they ignore everything else in my response, just pay a little more attention to this aspect of their practice.

MALAYSIA’S DOCTOR OF TOMORROW - Dato' Dr Ronald McCoy

MALAYSIA’S DOCTOR OF TOMORROW

Dato' Dr Ronald S. McCoy

Introduction

Medicine had its origins in ancient Greece in the 7^th century BC and is one of the oldest and most respected professions in the world. Medicine is an exquisite blend of science and art – the science of preventing, diagnosing and treating disease, based on scientific evidence, and the art of healing, which goes beyond diagnostic, therapeutic and technological skills.

Western medicine is based on mastering a core of knowledge, a code of ethics, and a scientific, systematic approach to decision-making, based on a predetermined model of disease. 

There is both an overt curriculum, made up of factual subject matter, and a hidden curriculum, made up of the high expectations of physicians by fellow physicians and society. It takes daunting years of training and apprenticeship to master the practice of medicine and become providers of competent, effective, appropriate, safe and patient-centred care. In fact, medicine is a life-long learning process and a compliant attitude to continuing professional development is essential.

The profession of medicine is essentially a vocation, distinguished by altruism and a sense of social responsibility. In recent years, medicine seems to have lost its way, lured by modern versions of the Greek mythological Sirens. 

In a rapidly changing world, medicine has sometimes come to resemble a nine-to-five job or a trade or even a business. Perhaps, benign neglect in teaching the philosophy of medicine and medical ethics, before and after graduation, has something to do with it. Perhaps, the lack of good role models is another factor.

Doctors face a shifting medical landscape and have to adapt and respond to changing patterns of disease and new epidemics; address rising costs of health care, growing patient expectations and demands of accountability, expressed in a patient’s charter; adjust to advances in medical and information technology; and consent to clinical governance and regulation.

The paradigms and pressures of the modern world appear to be submerging the core values of medicine. In some countries, there is political interference in the professional independence and integrity of doctors as well as the economic pressures of private enterprise and business, marketing and advertising, profitability and the bottom line. 

These paradigms are being embedded in a dynamic global culture, largely subsumed by the concepts market economics. While medicine cannot change all aspects of culture, nevertheless, the medical profession can and must offer resistance and exert its still considerable influence on society to ensure that negative influences do not degrade medical professionalism or undermine the qualities expected of a doctor. It is in such an environment that the doctor of today stands, gazing into the future.

Medical education in Malaysia

For those who contemplate a career in medicine today, beware the dangers of false expectations and a changing world view of medicine. Medical education in Malaysia sits uneasily on a national health system that is splintered into two and in urgent need of reform – a government-funded public sector for the poor and a separate private sector for the rich. 

Malaysia’s doctor of tomorrow will face many challenges:

·      First, the educational challenge of coping with the consequences of compromised education standards in government primary and secondary schools. In particular, low proficiency in the English language will shape and determine the level of tertiary education, including the teaching of medicine.   

·      Second, the challenge of ensuring that a culture of excellence will nurture medical schools with high standards and that the method of selection will lead to the admission of qualified students, capable of being trained to be competent and ethical doctors. This will depend on several factors:

The standards and requirements of medical education, set by the Malaysian Medical Council (MMC) and the Malaysian Qualifications Agency (MQA) are generally adequate, but there appears to be evidence of failure in implementation in some areas. These shortcomings can and should be rectified by the MMC. This is a particularly important aspect in profit-driven private medical schools and distant foreign medical schools.   

The accreditation of foreign medical schools merits the special attention of the MMC in critically evaluating teaching methods, quality of teachers and learning outcomes. The status of such schools should be closely reviewed and their graduates subject to a common qualifying examination, before they are registered as doctors. Reports from hospital consultants, who supervise the training of housemen, would help in assessing quality.

Education has become a relatively unregulated business in many countries. The damaging impact of agents in enrolling students in suspect foreign medical schools, which teach in a foreign language and have dubious standards, is a matter of great concern.

The problems of recruiting and retaining good clinical teachers and resisting political pressure to lower standards make it difficult to maintain a high standard of undergraduate and postgraduate medical education. The improvement of the doctor-population ratio should not be at the expense of quality.

There is a real danger of mediocre teaching, resulting from the brain drain of senior, experienced clinicians from teaching hospitals to the private sector, owing to the huge differential in income between the two sectors and the government’s misguided health tourism policy.

The separation of university teaching hospitals and government service hospitals should be reviewed and arrangements made to designate some government hospitals and staff as teaching partners.

Teaching methods in medical schools vary and can be problematical. The shift from a traditional curriculum to an integrated curriculum will require a concerted effort to orientate the teachers.

There is a need to regularize and modulate medical curricula in a transparent and accountable manner, as globalization and internationalization are beginning to transform medical education. 

An insightful curriculum will embrace patients and community needs, and equip students with skills to meet postgraduate challenges, including the need for effective use of medical knowledge, appropriate use of medical technology, the development of professionalism and medical ethics, and the need to restructure and redesign the programme for continuing professional development, in the face of an aggressive pharmaceutical industry.

In the medium term, there will be a need to cap the number of medical schools in the country, particularly private medical schools, and gradually reduce student intake to maintain an optimum doctor-population ratio.

Professionalism

Professionalism is an important attribute in any doctor. It is governed by an agreed set of rules and standards of practice and conduct, determined by the profession and society, in the public interest. 

It is important that the medical profession does not interpret professionalism as a licence to serve the interests of the profession itself, rather than the needs of the population it has a duty to serve. 

It also has a duty to maintain professional standards, independent of political or commercial influence, while always being accountable to the public. Apart from knowledge, it is professionalism, ethical practice and compassion that transform a doctor into a healer.

Despite modern health systems and profound advances in medical science and technology, patient-care studies show a steady decline in public satisfaction and trust in the doctor-patient relationship. Although a significant number of patients are satisfied with their individual doctors, there is discontent with the total health care experience. 

This has led to a growing movement towards alternative and complementary medicine. 

A Mori poll in 1999 asked a random selection of the public to say which professionals could be trusted to tell the truth. The results were: doctors 91%, judges 77%, scientists 63%, businessmen 28%, politicians 23%, and journalists 15%.

In recent times, there have been unsettling political trends in Malaysia. We have seen how the independence of the judiciary has been compromised and cowed by executive power. 

We have seen how some members of the medical profession have also been subject to political pressure.  They have recently come under close public scrutiny when they appeared to have succumbed to political pressure when making medical reports on custodial deaths. 

To give you some idea of the problem, between 2003 and 2007, there were 1,535 deaths in prisons, rehabilitation centres and detention centres for illegal immigrants, and very few of those responsible for the safety and well-being of those in custody have been tried or convicted.

The doctor of tomorrow will continue to be under political pressure, unless the medical profession today stands united and firm against the attacks on its professionalism, its independence, and its integrity. 

Until the Malaysian Medical Council (MMC) is reformed and its membership made up of a majority of elected members, it will not be an independent body. It will not feel empowered or inclined to proactively and independently scrutinize the veracity and credibility of medical reports on the causes of strange custodial deaths. In more enlightened countries, not only do national medical councils have a majority of elected members, they also include lay persons.    

Consensus Statement on the Role of the Doctor

In Britain in 2007, Sir John Tooke chaired an Inquiry into Modernising Medical Careers, which called for the profession to speak with a coherent voice and to define the role of the doctor. 

The profession heeded that call by organizing a conference, which issued a Consensus Statement on the Role of the Doctor. Among other things, the statement made the following points:

·      Doctors must be capable of taking ultimate responsibility for difficult decisions, drawing on their scientific knowledge and clinical judgement.

·      It agreed with the International Labour Organisation’s definition of the role of the doctor, namely, that the role of doctors as clinical scientists is to apply the principles and procedures of medicine,

·      supervise the implementation of care and treatment, and conduct medical education and research.

·      All doctors require a set of generic attributes to merit the trust of patients that underpins the therapeutic relationship. These qualities include good communication skills, the ability to work as part of a team, non-judgemental behaviour, empathy and integrity.

·      The nature of these core attributes emphasizes the need to select medical students with appropriate attributes for training.

·      All doctors have a role in the maintenance and promotion of the health of the population, through evidence-based medicine, health education, and health advocacy.

·      Within a world where the capacity to treat is growing but financial resources are finite, doctors have a duty to use resources wisely and effectively and engage in constructive debate about such use.

·      The role of the doctor is changing, alongside the needs and expectations of patients, who are increasingly better informed. The doctor acts as a partner and serves as advisor, interpreter and supporter.

So, there you have it! There is much we have to do in this country to strengthen the medical profession, reform the delivery and financing of health care, and improve medical education for Malaysia’s doctor of tomorrow. And, of course, change the political culture and structure!

Presented at a forum at the International Medical University on

5^th December 2009 on behalf of the Malaysian Medical Association.

NST Online Private doctors, staff also hit by H1N1

NST Online Private doctors, staff also hit by H1N1















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Have Doctors Been Complicit in Driving Healthcare Cost?

“Doctors have been complicit in driving up health care costs. They need to become part of the solution.” ~ Editorial: Doctors & the Cost of Care, New York Times, 13 June, 2009

“The greatest threat to America’s fiscal health is not Social Security. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.” ~ President Barack Obama, in a March 2009 speech at the White House.

“Medicine has become a pig trough here. We took a wrong turn when doctors stopped being doctors and became businessmen.” ~ Dr Lester Dyke, Cardiac Surgeon, McAllen, Texas


Healthcare Cost has Escalated
Last night, while I was having dinner with some friends, I was once again reminded that perhaps health care cost in Malaysia has escalated beyond the pale of inflation or affordability.

A close friend whose brother was suddenly taken ill with haemorrhagic fever was admitted into a Klang Valley hospital, where he developed complications one after another. He bled into the gut, and also into the brain, went into shock which also led to kidney failure. He was transfused profusely, had intensive critical care, required haemodialysis, and was consulted by at least 4 specialists including an internist, a nephrologist, a gastroenterologist and a neurosurgeon. Sadly, after 9 days of deteriorating multi-organ function, he died. And the bill exceeded an unexpected RM45,000.

That was the crux of the complaint—why was the bill so high, and was there any overcharging, and if not, were our doctors' billings too excessive, if not too exorbitant?

There was a suggestion that perhaps under such complex illness requiring multiple physician input and management, there could perhaps be more coordination, and perhaps an attenuated billing system of professional fees. The aggrieved family lamented that almost all the doctors charged the maximum complex fee for each visit, although, most of these visits appear cursory and lasted just a few minutes per time. The gentleman noted that some of the physicians did not simply consult with this one patient, but attended to a few others in the ICU at the same visit, so why had he charged so much?

To add fuel to the fire, when he complained to one of the hospital directors, he was told that nearly all the doctors had begun charging the highest rates ever since the new regulations came into being—putting squarely the blame on the Ministry of Health for including the fee schedule in the Private Healthcare Facilities and Services Regulations, in 2006. He further added that when the physicians first started practice at that hospital, they were all driving Protons, but now all have upgraded to expensive imported models!

Such fatuous unthinking comments can only contribute to unhappiness and feelings of possible overcharging in the minds of grieving relatives. These also underline the unspoken or misspoken envy that many hospital administrators harbour against many of our professional doctors, whom they perceive as perhaps earning too much!

This recent anecdote demonstrates the complex nature of the healthcare cost conundrum, not just in the USA, but closer home, in our own backyard as well.

Modern Medical Care is NOT Free Lunch
One sad fact which is misunderstood, is that healthcare is or should be readily affordable to everyone, including the least endowed. There is that public expectation that while life-saving care should be universally available, it should never be too costly, because this can potentially cause severe hardship to, or even bankrupt the victims of such unforeseen medical disasters.

But it is precisely these forms of catastrophic illnesses which are frightfully expensive; particularly when many high-tech measures have been engaged to try reverse or even to ameliorate deteriorating bodily functions.

Intensive care therapies with multiple organ support measures, including close monitoring and mechanical ventilation support, are very costly. Actual costs of using mechanical ventilation, oxygen therapy and supporting medications and close scrupulous monitoring, can easily rake up to RM3000 - RM5000 per day (excluding physician fees)!

Unfortunately again, this has not been made known to the public at large, because either some third party payer had been reimbursing thus far, or that many continue to assume that these therapies would be charged at rates equal to those at public hospitals.

Here is the conundrum: our public hospital charges are massively subsidised through our tax dollars! These are not free lunches, and cannot be transposed so easily into private settings, where every penny has to be counted and balanced!

Here too lies the failure of our government to address and expose the real cost of healthcare. We have been cross-subsidising healthcare costs for so long and offering our citizens' healthcare cost at such ludicrously low rates, that they have grown accustomed to these unrealistic levels.

Of the 12.9 billion ringgit government spending on health care, the public had paid only a miserly 2%, according to Health Minister Dato' Sri Liow. Thus, the public healthcare sector is 98% subsidised by our tax dollars!

Unfortunately too, our health insurance (private prepaid plans) take up is still notoriously low, with less than 15% (11.9 to 14.4%) of the private health care expenses being paid for by such means. Most private health care expenditure (73-75%) is still paid out of pocket!

Yet, most citizen and consumer groups are still clamouring for the continuity of such practices, believing that our poorer segments of society must never lose out to every 'reasonable' medical care whenever they need these. Just what is defined as 'reasonable' medical care remains to be agreed upon! Laudable as these social affirmative aspirations may be, they are seriously flawed, when we have an unapologetic proclivity to an undisguised market-driven economic model.

Until and unless this economic model changes, there is little hope for some semblance of balance in health care considerations. Hence, the reality bites are such that some form of rationing and queuing must accompany every possible healthcare system where we have finite resources, but infinite needs!

We simply cannot afford to offer every possible technologically-advanced therapy to everyone on demand! Or even on need! Someone has to pay for this, and even though most nations in the world claim to have some form of universal access to healthcare, none can ever offer every possible medical care to anyone, everyone, on demand, every time!

We simply have to understand that while we can strive toward some form of universal access to healthcare, we also have to accept that some degree of delay, queuing, even rationing based on cost-effectiveness and affordability will have to be made by some medical authority or health economist.

Our public must be made to understand that that is the social contract for cheaper or hugely subsidised healthcare—that some form of delay is inevitable and that everyone needs to be patient and trust that the system would be fair in its distribution of the healthcare largesse.

Others who choose to deviate from the common pool will invariably have to pay more, and perhaps in an unfair manner, may demand some quicker access, some queue jumping or even some more heroic therapeutic measures, which on economic grounds might not have been justifiable, without the extra infusion of cold hard cash!

Fair for some isn't fair for all. But such is the power of capital and greater funding... It does not pretend to be socialist or utopian in equitable distribution.

Modern Advances demand Greater Utilisation, hence Higher Costs
Modern advances in measures to keep patients alive or support their recovery, are often accompanied by extremely expensive techniques and medications. Sadly, the availability of these new advances have led to increased demand and utilisation, rightly or wrongly!

There has always been this tendency by health workers and doctors to use more devices, more tests, more new therapies simply because these are available. Increasingly, informed IT-savvy patients are now also demanding more that should be done, even with fringe or outside chance benefits!

Thus, inadvertently, doctors and demanding patients alike contribute toward this increased cost by utilising more resources.

Do these necessarily improve survival or save lives? Often this is difficult to calculate with certainty, although on the individual basis, most doctors would swear by their efficacy and cost-efficiencies—each life saved or improved, is nevertheless one more life salvaged—whatever the costs!

The reality is that we cannot afford this on a universal scale! So we will have to re-look into this system gone awry. We have to re-tweak the system to ensure that it does not self-destruct from institutional collapse!

With regards to the above unfortunate patient though, it is regrettable that he did not survive despite the heroic measures that were attempted to sustain him. But, were the costs justified? That is another question, which many doctors have to consider and contemplate more and more. We have to decide how much to do, to refer, to test, to treat, or to let go, on some of these difficult professional actions.

Should we now have to consider the economic angle early, even as we struggle our level best to salvage a critically-ill, even terminally-ill or futile patient, without being accused of despondent incompetence?

How much do we need to temper our increasing dependence on and utilisation of newer and newfangled devices and measures to artificially support failing bodily functions? Is the cost of terminal or futile care justifiable even if there was just that very slim glimmer of hope?

And finally, do we as physicians need to charge at our extreme limits just because these patients are difficult and complex to manage, although our actual consulting moments with our patients appear so transient, sometimes cursory, sometimes callous, to their loved ones looking in?

Do we need to educate our patients and their relatives that the medical consult is not simply that few minutes of coming by the patient, that cursory examining of their pulse, or BP, or a quick scan of the charts?

Should we inform them that deep within our buzzing minds, we are always contemplating, making algorithmic decisions and choices, interrogating test results and assimilating previously learnt knowledge, past training experiences and newer information, even as we just sidle past our bed-ridden patients and auscultate their chest, or palpate their abdomen, out of dispassionate automatism rather than unfeigned examination?

Must we indeed demand and earn our professional fee that we feel we are entitled to, rather than out of duty and compassion...? Are we guilty of contributing toward the skyrocketing healthcare costs, and shouldn't we perhaps learn to temper this relentless trend?

How much can we value our professional skills in terms of monetary equivalence—how much do we cost our services, and to which level are we willing to take this inchoate economic appraisal as an increasingly specific service commodity?

How can we temper our economic worth vis-a-vis our vaunted altruistic benevolent vocation, our professionalism in a consumerist market-driven economy? When is enough, enough?

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