Monday, September 12, 2011
On rounds, the attending of course pimped us about all the possible tests you could draw on a patient who comes in with a clot. I zoned out in my head since I know that regardless of the test results, pulmonary embolism is life-threatening enough that this patient will need life-long anticoagulation - the tests will not change anything. Even if the patient tested positive for genetic clotting diseases, there is no point screening family members or even considering anticoagulation in them unless they develop clots themselves. We went on a long and useless thought experiment. What bothers me the most is that we get a pat on the back when we try to draw these tests just because they are vaguely related to hypercoagulability, but when you actually stop to ask yourself what you would do if the tests come back positive, the answer is usually a shoulder shrug . Imagine the phosphatidylserine antibody came back positive - what does that even mean? and do we even care? I personally do not as the patient is going home with anticoagulation no matter what.
Useless thought experiments, unindicated lab tests and interventions happen on a regular basis, both in my medical school and residency program. We transfuse blood when there is no good evidence that it improves any outcome, just because doctors are nervous that patients will have heart damage from demand ischemia. Consulting surgeons would like to follow Lipase level in my patients with pancreatitis, and my attendings let them even though there is no evidence that its correlates with symptoms just because we don't want to get in a fight. I was told to perform extensive workup in a patient with acidemia, when the obvious cause of kidney failure stares us right in the face - I couldn't convince my attending to wait until the kidney failure resolves to see if the acidemia goes away, at which point no workup will be needed. We looked for zebras even though we know it's a horse, only because my attending "didn't want to miss anything."
In my opinion, most of what we do in medicine is not backed up by good evidence. A lot of the guidelines are biased by group interests and potential profits. This is part of the reasons why some of the tests/procedures that used to be indicated are no longer. Mammogram used to be recommended every year, but now yearly screening may lead to unnecessary breast procedures and once US Preventive Services Task Force tried to recommend increased screening interval, the backlash from groups that stand to profit from mammograms and breast procedures was overwhelming.
But a lot of it stems from how we are trained in medical school and residency. If we get a pat on the back every time we draw useless tests, we will continue to perform unindicated workup when we become attendings. If we are deemed unknowledgeable every time we refuse to do extensive lab work because we have a good explanation of what the abnormality is, we will spend more money without improved outcomes, which is happening in the US as we speak.
I wonder if my patient knew that the test for phosphatidylserine antibody costs $194 at our hospital, and that in the end the test will leave her with nothing better than less blood in her veins.
Thursday, June 30, 2011
It was a beautiful Monday morning in May. Yawning uncontrollably, I hopped into a Ford Hybrid with my attending and drove off to visit a patient who lived two hours away from our hospital. I woke up especially early that morning since we knew the commute would take many hours. We drove past open fields and a few cows before pulling into a driveway of a lovely house with a cute garden behind it. A middle-aged lady peered through the screen door and waved. My attending waved back as we clambered out of the car. She opened the front door and hugged my attending like a long lost friend, which she practically was, as they caught up over a short conversation before moving on to discuss her brother, Mr. R.
Mr. R was blind. He could not and had not left his one-windowed bedroom for many years. When my attending was called about Mr. R a few years ago, it was a consult for home visit evaluation for hospice - Mr. R had such severe COPD that his prior provider thought that there was nothing more medicine could do for him. When my attending first met Mr. R, he was in bad shape - he was bound by yards of oxygen tubes connected to a tank, however not quite long enough to reach anywhere but his bathroom across the hall from the bedroom. That did not matter much, since getting up from bed was a huge feat causing severe shortness of breath. The blindness did not help either.
My attending agreed to see him under special circumstances. Mr. R lived outside the usual range of home care visits provided by our hospital - she was hoping to set him up for hospice during a one-time visit. However, as she looked at Mr. R more closely, she realized that his COPD was not yet optimized and that medicine deserved a fighting chance. She set to work as his new primary care doctor, driving out to his house over the years to provide medical care - if Mr. R could not get up from bed without gasping hopelessly for air, there was no hope of traveling to the clinic for him.
I looked at Mr. R with a hidden surprise, watching him grin as my attending entered the room. He was thin with a well-kept white beard, looking incredibly full of life for someone previously considered for hospice. I felt his firm handshake and observed in quiet wonder - Mr. R was breathing normally, speaking in full sentences, on 2Liters of oxygen. He reported that he was doing very well, taking inhalers as prescribed and finishing the last of his prednisone taper, which allowed him to titrate his oxygen down to 2Liters. He could get up from bed and make it to the bathroom, although still short of breath by the end of his journey. He appreciated the visit by the good people at the blind rehabilitation center, who helped him cope with blindness and promised him a reading machine.
I stuck a pulse-oximeter on his finger, which beeped after a few seconds showing 94% oxygen saturation and a heart rate of 80 - his vitals were much better than my guesstimate. His lungs were a bit wheezy, although with good air movement. We drew his blood for testing and decided to adjust medication by phone after results came back. We concluded the visit - my attending gave him a hug and promised to follow up on his reading machine. As I asked Mr. R for a trash can to dump a piece of used gauze, a weird sense of humility hit me - suddenly I did not know where things were and was at the mercy of my patients, I could not go into other rooms or touch anything unless permitted by Mr. R - is this what patients feel like on our turf in clinic?
My attending talked with his sister in the hallway afterwards regarding the plans of care for Mr. R, and she thanked us profusely for making the trip out to her house - a familiar happening during a home-care visit. I took my last look at Mr. R facing the one window in his room, as if he was staring through it, and thought about how far he has come - from the brink of hospice to awaiting a reading machine. I turned around and climbed back into our vehicle, driving a long drive back to the city.
In this day and age when our population is growing older and fewer people have the time or resources to go to doctor's appointments, home care visits by doctors have become increasingly valuable and life-saving. Home-bound population is greatly underserved, and capacity for home-care visits is limited, most of all by time and distance. Doctors can only travel to so many patient destinations in a day.
With the increasing popularization of mobile technology, a new model for home care visits emerged - one that could save time, expand home-care capacity and utilize community-based health care. I amateurly dubbed it, "The Home-Care Node System."
The Home-Care Node System consists of two major nodes: a single physician node in the center at the hospital interacting with multiple allied health nodes situated in the patient's neighborhood. In the node system, physicians make the first home-care visit along with a team of allied health professionals (who live near the patient) to perform initial intake together - the team can perform physical exams first-hand to document an agreed baseline on the patient. For subsequent follow-up visits, allied health professionals become the eyes and hands for physicians. They go out to patient's home, easily since they live nearby, equipped with a video-ready device (maybe an iPad, maybe a laptop, fill in your own blank here). Video conference is linked to the physicians at the central node, allowing them to take history, maybe take a look at a rash on the patient's foot, and listen to reports from allied health professionals who can answer any questions that video footage or patient's account cannot answer. Allied health professionals can take vital signs or draw labs if needed.
The only missing ingredient is the ability to repeat physical exams by the physicians in person, but I argue that this is not extremely important. Allied health professionals can perform the physical exam and share their findings with the physicians. Most physical findings that matter do not require MD training to recognize. If a wheeze is too tiny for an untrained ear to hear, then the lungs are practically moving good air on the grand scheme of things. If a wheeze is prominent and diffuse, a medical student will hear it and so will a physician attending. If there is any doubt, a physician can make a special trip to the patient's house to investigate further, but for all other non-subtle findings, allied health professionals in the area can free physicians to take care of more patients in wider areas of service. There is also much to be said about community-based health care - local allied health professionals understand the environment that the patient lives in and have invested interest in improving the health of their community.
The Home-Care Nodes will not be easy to set up in our maze of a health care system, but a lot of great inventions sprout from what-ifs that were given a try. As I sat down to write my home-care visit note for Mr. R and pondered about how far he has come, I daydreamed of a day when home-bound patients are adequately and efficiently served. But then again, daydreaming is a powerful thing – as long as we act on it.
Tuesday, June 28, 2011
Thursday, May 5, 2011
On the night of October 4, 1984, a young girl named Libby Zion was admitted to New York Hospital in Manhattan for fever, agitation and strange jerking movements. No one knew that her death the next morning would, 27 years later, drastically change the quality of physician training, for better or worse.
When Libby was evaluated in the emergency room that night, neither the ER physician nor her family physician Dr. Raymond Sherman, consulted by phone, were able to make a definitive diagnosis of what was going on with Libby.
They decided to admit her for hydration and observation. When an intern Dr. Luise Weinstein and a resident Dr. Gregg Stone evaluated her for the admission, they also were not sure of Libby’s cause of illness – Dr. Stone termed it “a viral syndrome with hysterical symptoms,” suggesting that Libby may be overreacting to a benign viral syndrome. They prescribed her Meperidine to control shaking, and Dr. Sherman approved the plan by phone without evaluating the patient. Dr. Weinstein went on to care for 40 other patients in the hospital that day, while Dr. Stone went to sleep in the next building, to be reached by beeper if needed.
Later on that night, the nurse contacted Weinstein when Libby became more agitated and started pulling out her intravenous lines. Weinstein ordered restraints and Haldol, a medication used for agitation, without re-evaluating the patient. She also did not notify Stone or Sherman. Libby finally calmed down later that morning, until 630 AM when a vital sign check showed that Libby had a dangerously high fever to 107. Measures were taken to reduce her temperature, but Libby soon suffered cardiac arrest and died.
On careful review, it was discovered that Libby was taking an antidepressant named Phenelzine. Combined with Meperidine given to her in the hospital, Phenelzine can cause fatal serotonin syndrome, symptoms of which include hyperthermia resulting in cardiac arrest.
What follow were outraged parents, a high-profile court trial and the image of the bedraggled, unsupervised intern wreaking damage in hospitals featured in the pages of the Washington Post, the New York Times and Newsweek. Libby’s parents believed that her death was caused by inadequate supervision and fatigue from long work hours. This sparked work hour regulations for residents and interns, which continued to evolve even 27 years later. In 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced stricter work hour regulations, from 30-hour shifts in 2003 to 16-hour shifts to take effect in July 2011. It also stipulated that residents must have 8-10 hours off between shifts, with total work hours/week not exceeding 80 hours.
I have the distinct fortune of being the intern during this monumental transition – I am the only group of interns who during my first year of training have the opportunity to work 30-hour shifts while also transitioning to the 16-hour calls. As I keep my head above ground while my residency program goes through multiple trials of work hour changes to meet the new standards, I often ponder (despite lack of time) about what happened to Libby.
Looking carefully at the story, Libby did not die simply because interns were taking 30-hour calls. When Libby presented, multiple physicians missed her diagnosis, including the more experienced ER doctor and the Zion’s family physician, who should know that his patient Libby was taking Phenelzine before she came to the hospital. The decision to give her Meperidine was not made by the residents alone – it was approved by the well-seasoned, board-certified family physician Dr. Raymond Sherman. When Weinstein decided to give Libby restraints and Haldol, she was probably tired, but more importantly she was BUSY – she did not re-evaluate Libby or call for help, not because she was sleeping, but because she was covering 40 other patients.
Libby highlighted what was and is wrong with medicine today. Private physicians cannot and should not be allowed to manage patients who are sick enough to be admitted by phone – Experienced physicians need to evaluate patients in person and should not rely solely on residents’ accounts. Medication reconciliation and prevention of medication cross-reactions should not be left vulnerable to human errors and information technology needs to be effectively used.
Most importantly, from personal experience, I can testify that as an intern, I am more likely to make medical errors because I have to take care of an absurd number of patients, not because I am tired, and cutting calls from 30 to 16 hours will only exacerbate the situation. As my call hours are cut to sixteen, I am still forced to admit the same overwhelming number of patients I usually do on a 30-hour shift. As I struggle to get out at the 16th hour, there were numerous orders that I simply did not have time to execute, and the fate of the patients are left to the residents who stay overnight for 28-hour calls but remain overwhelmingly overworked. As I lose post-overnight call resting hours and accumulate more commute time from not being able to stay in the hospital, I end up spending MORE time working and less time sleeping. As I become more tired and take care of more patients in shorter periods of time, my learning has greatly diminished – I spend less time processing my patients and more time cramming 30-hour worth of paperwork into 16-hour shifts.
The solution stares us in the eye – interns need a stricter cap on the number of patients they can admit or care for at one time. Patient care can be improved and medical errors can be avoided if providers simply have more time – thorough assessments can be made and comprehensive plans can be formed. Sixteen-hour shift is not the answer – it only aggravates the actual source of the problem