Better Health: Smart Health Commentary

Featured

Good Medicine Is About Good Relationships

September 4th, 2009 by admin in Better Health Network, True Stories

Tags: Edwin Leap, Emergency Medicine, Knowing Your Patient, Long Term Relationships, Psychiatry, Psychology

By Edwin Leap, M.D.

An emergency physician, like me, may be the worst possible person to discuss relationships with patients.  I mean, one of the reasons I chose this specialty was that I didn’t want long-term relationships with my patients.  I see, now, that God has a great sense of humor.

See, the county I landed in after residency is small enough that I do know many of my patients, and I do see them more often than you might imagine.  After all, our hospital is ‘the only game in town.’

There are some patients I know quite well, and thus I know with reasonable accuracy who is sick and who isn’t, based on how they looked or behaved before.  It doesn’t always work, but frequently it does.

Which brings me to trends in primary care.  I don’t know if I’m really a primary care provider or not.  Some years we are, some years we’re considered specialists.  Whatever.  It doesn’t really change the work.  It might change the pay, as administrations place different emphasis from time to time.  But I do see a lot of primary care.  I watch internists and pediatricians, family physicians and ob/gyns do their work.  And what I see, from the standpoint of the emergency room, is a drift away from relationship.

The thing that brings it up most poignantly is the trend towards hospitalists.  For those of you not acquainted, the hospitalist is a physician whose practice is focused on admitting patients to the hospital, caring for them, and discharging them back to their regular physicians (if they have one) when the acute situation is over.

Now, I know some great hospitalists.  And I understand the need for them.  As hospital care becomes more complex, as offices suffer when their docs are at the hospital, as the goal becomes ‘discharge as soon as possible,’ wherein utilization review committees are prime-movers, the idea of the hospitalists makes great sense, and probably bears much fruit.

However, a relationship is severed.  We have many community physicians who do not do hospital work.  And more now that the hospitalist option exists.  So let’s say I have patient X in the evening or on the weekend.  His physician doesn’t admit.  I call the hospitalist.  ‘Patient X is having chest pain.  His cardiac labs and EKG look alright, but it just seems concerning to me.  Can we admit him?’  Hospitalist:  ‘well, he doesn’t have risk factors and everything looks OK, what are we going to do?  Do a second set of labs and let him see his doc tomorrow.’

Now, that was a technically correct encounter.  But if his own doc had been on call, as in the past, he might have said ‘I’ve known him for years.  He doesn’t complain.  That isn’t like him.  Let’s keep him overnight.’  Scientific?  Maybe not.  Possibly useful?  Absolutely.

See, the hospitalist is driven by admissions and discharges.  And he or she has no abiding relationship with these patients.  In the same way, the family physician who won’t admit has severed his relationship.  ‘So, I see you were admitted last week!’  He’ll get a report.  But the next serious illness that comes around will still be a situation in which the patient is admitted to a stranger with a lack of personal interest (I don’t mean that they don’t care, just that they aren’t personally connected over a long period of time).

I see both sides.  The hospitalist has a focused mission and a busy service.  The family doc has a focused mission and a struggling office to run.  But somewhere in between is the patient, who has been left afloat between two continents.  I guess the ER is the ‘desert island’ in between.

I don’t know the answer.  But I know that when they come to my emergency department, I have

Doctor and boy looking at thermometer, Norman Rockwell

to  put together the pieces and do the right thing.  I don’t have all of the information.  But before you scream ‘EMR,’ remember that medicine is more than data points.  Even if I have the data, I don’t have the sense of the patient.  The knowledge his or her physician has from personal, repeated interaction.

So I have to put the data together, decide if it heralds something perilous, and then I have to be a salesman…just to get someone else to look at the patient.  I am, in a sense, a voice-activated robotic surrogate for everyone; from family physician to hospitalist, obstetrician to urologist, ENT to general surgeon.  But then, that’s another post altogether.

What I mean to say is, when we lose relationship, we lose some of the most important bits of information in all of medicine.  Humans are complex, and in order for us to care for them, at least in the setting of being hospitalized or discharged, it’s remarkably useful to know them.

What do we do to fix it?  I have no idea.  I don’t believe it’s a thing that can be repaired with compensation schemes.  Perhaps only philosophically, as we teach young physicians the value of relating to their patients more than scientifically.  Or if it works better, to explain to them that science is more than labs, stress-tests, x-rays and biopsies.  Science is the pursuit of knowledge.

And patients are best known by…knowing them.

How’s that for a koan?

Edwin

CT Scan Of The Week: Death Lungs

September 3rd, 2009 by scanman in Better Health Network, True Stories

Tags: CT Scan, Lung Cancer, Metastases, Oncology, Pulmonology, Radiology, Scanman

…

The worst case of pulmonary metastases that I have seen. 40-year-old woman, operated for primary lung malignancy (adenocarcinoma) a year ago. Note the reduced lung volume on the right side.

Further Reading:

*This blog post was originally published at scan man's notes*

Medicare & Private Health Insurance: Monkey See, Monkey Do

September 3rd, 2009 by Shadowfax in Better Health Network, Health Policy, True Stories, Uncategorized

Tags: Aetna, CMS, Health Insurance, Medicare, Never Events

File this under utterly predictable:

Aetna tightens payment policies on hospital errors – Modern Healthcare (sub req)

Aetna has established new, tighter policies dictating when it will and will not reimburse for medical care related to errors made by providers.

Under the policies, Aetna has broken errors into two categories: “never events”—three events involving surgery: wrong patient, wrong site and wrong procedure—and 25 serious reportable events as defined by the National Quality Forum. Providers will not be reimbursed for a case involving one of the three never events, under the new payment policy. Of the 25 events, eight will be reviewed by Aetna to determine whether reimbursement should be withheld. The rest of the events will also be reviewed under Aetna’s new policy, but they will not be considered eligible for adjustments to reimbursement, the spokeswoman said.

This of course follows on the heels of Medicare’s decision not to pay for such events. The good news is that, as far as I can tell, Aetna has not extended the policy as far as Medicare has. Medicare, you may recall, also decided not to pay for certain (arguably) preventable conditions, such as foley-catheter-associated urinary tract infections, and surgical wound infections. Aetna, at least for the moment, is limiting its policy to the more black-and-white “never events” as defined by the National Quality Forum: items such as wrong-patient surgery or death due to contaminated medications.

I mention this not to rail against these standards or against the notion of incentivizing hospitals financially to avoid errors, but to highlight how rapidly and directly Medicare policies are aped by private insurers to the point that they become industry standards.

*This blog post was originally published at Movin' Meat*

My First Day As A Doctor

September 2nd, 2009 by Dr. Val Jones in True Stories

Tags: First Day As A Doctor, Intern Year, Internal Medicine, Patient Care, Patient Death, Physician

This post is a “Dr. Val classic” – first published in early 2007.

***

Internship, for those of you who may not know, is the first year of residency training.  It is the first time
that a doctor, fresh out of medical school, has responsibility for patient care.  The intern prescribes medications, performs procedures, writes notes that are part of the medical record, and generally learns the art of medicine under the careful watch of more senior physicians.

Internship is a frightening time for all of us.  We’ve studied medicine for 4 years, memorized ungodly amounts of largely irrelevant material, played “doctor” in third and fourth year clerkships, but never before have lives actually been put in our hands.  We know the expression, “never get sick in July” because that’s when all the well-intentioned, but generally incompetent new interns start caring for patients. And so, we tremble as we begin the new stage in our careers – applying our medical knowledge to real life situations, and praying that we don’t kill anybody.

I’ll never forget my first day of internship.  I must have drawn the short straw, because not only was I assigned to the busiest, sickest ward in my hospital (the HIV and infectious disease unit), but I was on call that day (so I’d be working for 24 hours straight) with the most hated resident in the program (he had a reputation for treating interns poorly and being arrogant to the nurses).  As I reviewed my patient list, I noticed that the sign out sheet (the paper “baton” of information handed to you by the last intern who cared for the patients – meant to give you a synopsis of what they needed) was supremely unhelpful.  Chicken scratch with diagnoses and little check boxes of “to do’s” for me.  I was really nervous.

So I began to round on my patients – introducing myself to each of them, letting them know that I was their new doctor.  I figured that even if I couldn’t completely understand the sign out notes, at least by eye-balling them I’d have an idea of whether or not they were in imminent danger of coding or some other awful thing that I figured they’d be trying to do.

My third patient (of 15) was a thin, elderly Hispanic man, Mr. Santos.  He smiled at me when I came
in the door – the kind of lecherous smile that a certain type of man gives to all women of child bearing age.  I ignored it and introduced myself in a professional manner and began to check his vital signs.  I was listening to his heart, and I honestly couldn’t hear much of anything.  There was a weird, very distant beat – something I wouldn’t expect for such a thin chest.  The man himself looked awful, but I really wasn’t sure why – he just seemed really, really ill.

My pager was going off mercilessly all night.  I wondered if this was how the nurses got to know the characters of their new interns – to test them by paging them for anything under the sun, tempting us to tip our hand if we had tendencies to be impatient or disrespectful.  But in the midst of all the “we need you to sign this Tylenol order” pages, there came a concerning one: “Hey, Mr. Santos doesn’t look good.  Better get up here.”

My heart raced as I rushed to his bedside.  Yup, he sure didn’t look too good.  He was breathing heavily, and had some kind of fearful expression on his face.  I didn’t really know what to do, so I decided to call the resident in charge (much as I was loathe to do so, since I knew he would humiliate me for bothering
him).

The resident appeared in a froth – “Why are you paging me?  What’s wrong with the patient?  Why do you need me here?  This better be good!”

“Um… Mr. Santos doesn’t look too good.” I said, frightened to death.

“What do you mean ‘he doesn’t look too good?’  Can you be a little bit more specific” he said, sarcasm dripping from his tongue.

“Well, I can’t hear his heart and he’s breathing hard.”

“I see,” said the resident, rolling his eyes.  He marched off towards the patient’s room, certain to make an example of me and this case.

I trotted along behind him, hoping I hadn’t been wrong in paging him – trying to remember the ACLS
protocol from 2 weeks prior.

The resident drew back the curtain around the man’s bed with one grand sweep of the arm.  “Mr. Santos,
how are you doing?” he shouted, as if the man were deaf.

The man was staring at the wall, taking in deep, labored breaths of air.  I saw that the resident immediately realized that this was serious, and he placed his stethoscope on the man’s chest.

I approached on the other side of the bed and held his hand.  “Mr. Santos, I’m back, remember me?”  He smiled and looked me straight in the eye.

He replied, “Angel.” (in Spanish)  Then he let out a deep breath and all was silent.

The resident shook the man, “Mr. Santos?  Mr. Santos?!”  There was no response.

“Should I call a code?” I asked sheepishly.

“Nope, he’s DNR,” said the resident.

I was flabbergasted.

“Yep, you just killed your first patient.  Welcome to intern year.”

As I thought about his cruel accusation, I was comforted by the fact that at least, as Mr. Santos released his final breath, he thought he had seen an angel.  Maybe my presence with him that night did something good… even though I was only a lowly intern.

Accepting The Death Of My Mother

August 31st, 2009 by Jon LaPook, M.D. in Better Health Network, True Stories

Tags: Death, Elsa LaPook, Jon LaPook, Loss, Mother, Mourning, NYT, Poem, Remembering

For years my friends and patients have told me how surprisingly shocking the death of an elderly parent can be.  We know it’s inevitable yet the finality is jarring.  But knowing and KNOWING are two different things.  So her son the doctor reacted just like so many others when my mother died unexpectedly last March at 86 after falling and striking her head.  I found it hard to get my arms around the idea that my mother was no longer alive.

I received an outpouring of beautiful condolence letters and contributions but have only written a handful of thank you notes.  My undoubtedly over-simplistic armchair psychiatrist explanation is that if I don’t write the notes then maybe she didn’t die.  And I’m not alone in my behavior.  My 90-year-old father, married to my mother for over 66 years, asked me a few months after her death if it was ok that he was pretending she was still alive.  “Absolutely,” I replied.  “That’s why God invented denial.”

My mother lived totally in the moment.  She’d start to peel an orange and would say “at this moment this orange hasn’t seen the light of day.”  Every morning she would look out the window at our breakfast table and say, “Good morning, dogwood tree.”  More often than not, whatever she was experiencing was “the best ever.”  The best ever sunset was the one she was watching.  The best ever salad was the one she ordered at our last lunch alone together a few weeks before she died.  Her best ever meal was the one she had just finished.  She did not want to waste a single second, as was reflected in a hilarious essay she submitted to the New York Times upon turning 75.  It was rejected; so here is the world premiere {link to NYT submission below}.

My wife had the idea to plant a dogwood tree on the top of the beautiful Vermont hill where we had sprinkled my mother’s ashes.  Yesterday my family gathered under cloudy skies for the ceremony.  One of my two sons sang a beautiful song he had composed using the lyrics of a poem called “Growing” that my mom had written when my three sisters and I were little.

Growing

Goodnight sweet baby and goodbye
I’ll see you as you are no more.
For dusk has settled in the sky
And you have wondrous dreams in store.
As you sleep, a magic hand will touch you
And you’ll grow more wise.
Tomorrow morning you’ll awaken
New and different in my eyes.

This morning my father admitted that he still finds it hard to accept she’s gone and sometimes imagines that “she’s just out shopping.”  But we’re both starting to accept that we’ll see her as she was no more.  This afternoon I’m going to start writing thank you notes in earnest.  Well, maybe tomorrow.

***

Dear Editor:

I just celebrated my 75th birthday, and do you know what?  I’m better than ever!  Well, I guess you could say I’m stronger than ever.  No, not in my muscles, which can be developed and maintained during regular workouts in the gym, but in my mind, which gets a daily ongoing on site workout.  I now have the strength of my convictions, something I never had when I was young because in those days I always aimed to please, so that everyone would like me.  I have now become much more assertive, more determined, more stubborn, and more aware of the passage of time, and as I calculate how much of it I have left, I have made a firm decision not to waste one moment of it.

With that thought in mind, here are some resolutions I’ve made to myself for the New Year:

1. I will not open unsolicited advertisements in the mail.  This includes 10 million dollar lotteries and free trips to the Caribbean.  Into the garbage they go!

2. I will not make dinner dates with boring people.  This includes people who didn’t used to be boring but are now.

3.  I will not put off doing things that I want to do.

4.  I will not attend meetings out of a feeling of obligation.

5.  I will not play singles rather than doubles in tennis or play an extra hour because I’m afraid to say no.

6.  I will not ride when I can walk or walk when I can ride, depending on how I feel at the time.

7.  I will not take part in long phone conversations with talkative people who are boring.

8.  I will not dress up to go out if I feel like wearing a shirt, sneakers and jeans.

9.  I will not shop ’til I drop.  I never did and I certainly won’t start now.

10.  I will not agree with someone unless I really do.  I won’t be afraid to express my opinion.

11.  I will hang up instantly on phone solicitors with no apology whatsoever.

12.  I will remove the tag from each and every mattress that I own with absolutely no fear of penalty of the law, and when I make the bed I won’t always do hospital corners.  Sorry, Mom!

13.  I won’t be afraid to break a date if something better comes along.

14.  I plan to make a lot of money selling something on Internet.  Don’t know what yet.

15. I will not be intimidated by a surly maitre d’ or waiter. I won’t be afraid to send something back if it’s not to my liking, and if the rolls aren’t hot, back they’ll go.

16.  I’ll squeeze the toothpaste from the top of the tube–so there!

17. I’ll watch every Seinfeld rerun, all Frasier episodes and all Woody Allen movies.

18. I will wear white before Memorial Day and after Labor Day if I want to.

19.  I will always remember that health takes priority over everything, and I will guard it carefully.

20.  I will keep smelling the roses and seeing, tasting, touching and hearing the world about me for a long, long time.

Happy New Year!!

Elsa LaPook