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Book Review: Time to Care: Personal Medicine in the Age of Technology

time2careIn 1925, Francis Peabody famously said “The secret of the care of the patient is in caring for the patient.” A new book by Norman Makous, MD, a cardiologist who has practiced for 60 years, is a cogent reminder of that principle.

In Time to Care: Personal Medicine in the Age of Technology, Dr. Makous tackles a big subject. He attempts to show how modern medicine got to where it is today, what’s wrong with it, and how to fix it. For me, the best part of the book is the abundance of anecdotes showing how medicine has changed since Dr. Makous graduated from medical school in 1947. He gives many examples of what it was like to treat patients before technology and effective medications were introduced. He describes a patient who died of ventricular fibrillation before defibrillators were invented, the first patient ever to survive endocarditis at his hospital (a survival made possible by penicillin), a polio epidemic before polio had been identified as an infectious disease, the rows of beds in the tuberculosis sanitariums that no longer exist because we have effective treatments for TB.

He tells funny stories: the patient who was examined with a fluoroscope and told the doctor he felt much better after that “treatment.” He describes setting up the first cardiac catheterization lab in his area. No one who reads this book can question the value of scientific medicine’s achievements between 1947 and 2010. Today we can do ever so much more to improve our patients’ survival and health. But in the abundance of technological possibilities, the crucial human factor has been neglected.

Individualized care, which involves the use of science-inspired technology, is not personal care. Alone, it is incomplete. It does not provide the necessary reassurance that can only be provided through a trusted physician who focuses upon the totality of the person and not just upon a narrow technological application to a disease. Time and personal commitment are needed to build the mutual understanding and trust that are fundamental to personal care….the continued acceleration of science, technology, and cost has intruded on personal care in our country. This has also occurred during a time in which American individualism and its accompanying sense of entitlement have become more of a cult than ever before. In the absence of personal attention, patients demand more testing, but testing does not satisfy the need for personal interaction.

Makous invokes the Golden Rule: “Over the course of my career, I learned to treat patients as I would like to be treated under similar circumstances.”

Some of his recommendations:

  • Unhurried visit
  • Undivided attention to patient (not to chart or recording device)
  • Sitting down to talk to the patient
  • Laying on of hands
  • Humor
  • And finally, “Most patients will choose a doctor who enjoys their company.”

Makous points out that the “holistic” approach to medicine is nothing new: Hippocrates introduced the concept in the 5th century BC and good clinicians have always used it.

Medicine is an applied science, not an exact science, and often the best the physician can do is make an educated guess. The better the doctor knows the patient and the better he incorporates the personal element of care, the more educated the guess. For instance, knowing whether a patient is typically stoic or a complainer helps us decide how seriously to take his complaints. The “worried well” typically complain about every little thing; the stoic may not realize they are ill until they can’t get out of bed.

He thinks that evidence-based medicine only helps with about 5% of a physician’s work. Surely evidence-based medicine constitutes a larger percentage than that, but perhaps what he means is that when he is trying to make a difficult clinical decision there is only a pertinent, useful clinical study to guide him in about 5% of cases. Study populations may not be representative of the individual in the doctor’s office. Studies isolate one condition: your patient may have many others. “No study has been done that can’t be faulted in its extrapolation to the individual.” Most studies generate as many questions as they answer.

I agree with much of what he says, but then he goes too far:

The assumption is that physicians relying on personal experience have been on the wrong track and their practices need to be changed. In reality, the opposite is true.

No, relying on personal experience is a recipe for self-deception, and those practices need to be tested. There’s a danger in too much “personalization” of medicine: the doctor can be seduced into believing he is wiser than he really is and into rejecting science. If you think every patient is so different that scientific studies don’t apply, then anything goes. You can find an excuse to try any treatment you can think of. This is similar to the pitfalls of CAM’s claims of individualized treatment, as recently described by David Gorski.

Doctors today must please two masters: the patient and the healthcare organization. Care is fragmented, and specialists feel obligated to do more tests. Consultants often assume they are expected to do certain tests rather than to decide for themselves if the tests are really warranted. They are concerned about liability if they fail to do a test. They are reimbursed for doing the test, but are not reimbursed for the time needed to evaluate the patient holistically and determine if the test is really in his best interest. They are content to assume that the referring physician has already done that. But the referring physician may not know enough about the test to decide, and he may be assuming the consultant will decide appropriately. Costs and malpractice litigation rise as a result. Poor Medicare reimbursement means many doctors are refusing to accept new Medicare patients. We need a system to get more compassionate care to geriatric patients, more time with their doctors, not more technology.

Physicians are reimbursed lavishly for doing procedures but not for spending extra time talking to patients. They are not reimbursed adequately for counseling about preventive measures. Makous suggests that detailed advice on obesity and smoking might be better addressed as a public health concern and provided by non-physicians.

This is a thoughtful book by a wise old soul who has “been there, done that.” It is well worth reading for the insight it provides into recent medical history and for its reminder that doctors should treat patients as they themselves would want to be treated.

*This blog post was originally published at Science-Based Medicine*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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