Friday, March 31, 2006

Why do we round at dawn?

In the realm of medical practice, it's a small thing, but I suspect it's emblematic of what's wrong with the doctor patient relationship. I'm talking about hospital rounds. It varies from specialty to specialty of course, but most doctors make rounds at dawn.

I understand that this is because it's convenient for us as doctors. We see our hospitalized patients before the operating room opens, or before we head to our office. It's not convenient for the patients, though. In fact, it's worse than inconvenient for several reasons:

Hospitalized patients are (by definition) sick. They need rest to heal, yet we wake them up.

The patients are often slightly disoriented because we have just awakened them. In that state they find it difficult to remember what we told them and they forget to ask what questions they may have.

It is dawn so they are very unlikely to have family present. There is no one to help remember and corroborate our instructions. For patients who are very ill or confused, there is no family member present to ask questions, to inquire about the plan of care, or the plans necessary for discharge.
On balance, it's clearly a very bad idea to round at dawn. Why don't we change it?

Wednesday, March 29, 2006

What you eat does not determine your health

There have been several insightful comments posted in response to my rants. One thread in particular has generated a lot of back and forth, and I'd like to bring it out from hiding under the comments heading of the C-section post.

The discussion is about the role of lifestyle in promoting health and you can read the beginning of it below. I'd like to respond specifically to the comments of Marcus from Fixin' Healthcare. I want to thank him for being willing to engage in this debate, since he undoubtedly has many other commitments on his time.

I'll not quibble about various specific claims, like whether processing food concentrates calories and whether that has a meaningful impact on intake or health. However, I will return to the larger point. There is really not much scientific evidence to suggest that what you eat has any impact on health (besides specific dietary deficiencies) and that the amount that you eat (except at the extreme of morbid obesity) has an inordinate impact on health.

Basically, I am taking issue with the claim that you can meaningfully affect your health by manipulating your dietary intake.
As you know, nutrition does not lend itself to the types of clinical trials that we would consider scientific evidence or proof. Much of the evidence comes from identification of biochemical pathways and non-rigorous epidemiological observations."
Nutrition does not lend itself to cross-over double blind studies, that's true. However, there is a panopoly of statistical tests and measurements that can provide evidence for specific claims, and even that kind of evidence is lacking in the case of dietary intake and health.

When it comes to the study of specific metabolic pathways, I would argue that extrapolating from in vitro experiments to dietary recommendations for entire populations is entirely unjustified.

The bottom line is this: individuals gain minimal, if any, control over their health by changing what they eat.

Monday, March 27, 2006

The Obesity "Epidemic": A Cause for Celebration!

I am alternately amused and irritated by the hullabaloo surrounding the supposed obesity epidemic. First of all, people are not dropping like flies from obesity. Anyone who spends a fair amount of time in hospitals can attest to that. There are many people in the hospital because they smoke or they drink, but there are very few people in the hospital solely because they are overweight.

That’s not to say that obesity hasn’t increased. Of course it has. However, rather than being a dire calamity, it is a milestone in the history of medicine. Imagine, if you will, all the healers and practitioners down through the ages trying to conceive of a time when smallpox, diphtheria and yellow fever were not scourges. Could they ever have expected that a time would come when the most serious result of childhood illnesses would be lost school days instead of lost lives? It would have been beyond their wildest dreams to envision a society in which people had enough to eat, let alone more than enough.

The obesity “epidemic” is a direct result of the success of modern medicine (not to mention modern farming, and probably capitalism, too). As physicians, we are privileged to live in a time and place where obesity could possibly be a concern. Instead of wringing our hands, we should be thrilled that we have managed to make this possible.

Sure, we should be counseling patients about healthy eating and healthy weight, but we should recognize this for the important milestone that it is: so many childhood diseases have been vanquished, so many epidemics have been prevented or treated, and perennial food shortages have been relegated to the past. These achievements have allowed us to reach a time when eating too much is a health problem.

Sunday, March 26, 2006

Why is the C-section rate so high?

From Fixin' Healthcare:

For example, what is going on with care during pregnancy and delivery? This is a biological process that in the absence of complications cannot be improved upon with technology... Yet, beginning in the 1970s the incidence of C-sections rapidly increased.
As an obstetrician, there is very little that makes me angrier than attempts to blame the outrageous C-section rates on obstetricians.

First there is the pernicious blather about how pregnancy as a “natural condition”. Doctors, especially, should know better. Pregnancy is the single most dangerous phase of the average woman’s life, excluding old age. That’s despite the fact that modern obstetrics can successfully treat virtually all pregnancy complications. Historically, pregnancy was extremely dangerous. All you have to do is take a stroll though an old cemetery and see how many young women are buried there, victims of the “natural” state of pregnancy.

Complications in obstetrics are common, not rare. That’s in keeping with the fact that human reproduction on the whole is an extremely wasteful process. The gross excess of gametes, the high miscarriage rate, and the incidence of deadly pregnancy specific diseases like pre-eclampsia are just part of this.

Pregnancy is not “designed” to turn out fine; it is not “designed” at all. It is the results of millions of years of evolution balancing competing evolutionary benefits. For example, it is better for babies to be born with greater neurological competence (and therefore bigger heads), but it is harder for women to walk with a pelvis larger than certain dimensions. Those evolutionary needs have been in tension for millennia. The result is that often babies are too big to fit. In the good old days, women who could not accommodate a large baby died after an agonizing three days of obstructed labor. Or perhaps, they didn’t die, but the dead baby was removed in pieces and the woman suffered a recto-vaginal fistula that left her a pariah. Nowadays such women have a C-section and never stop to consider it a life saving procedure.

Before the advent of modern obstetrics, the most common causes of death in pregnancy were eclampsia, hemorrhage, infection, ectopic pregnancy, embolic phenomena and cephalo-pelvic disproportion. None of these are lifestyle issues. Many of these have benefited from the liberal use of C-sections.

Pregnancy demands a healthy diet.
No it doesn’t. More than 99.9% of all babies ever born were born to women who lived on subsistence diets. The impact of diet on pregnancy is minimal.

Yet beginning in 1970, the incidence of C-section rapidly increased.
You bet it did, and it had absolutely nothing to do with lifestyle. It’s because obstetricians are trying to prevent malpractice suits. It is virtually impossible to defend yourself in a “bad baby” case if the baby was born by vaginal delivery, even if C-section would not have made any difference at all. Pregnancy in its “natural” state results in many dead babies. Pregnancy in its modern state considers dead babies unacceptable and physically or mentally compromised babies are even worse.

Any risk of any kind is now unacceptable. The incidence of C-sections was rising in the 1990’s because of the safety of VBAC (vaginal birth after C-section). That was completely derailed when administrative organizations like ACOG announced that the risk of VBAC warranted in house anesthesia and 24 hour doctor attendance. For most small hospitals, it thereby rendered (unnecessary) repeat C-sections mandatory.

The role of lifestyle in health is grossly exaggerated (it’s wishful thinking more than anything), but the role of lifestyle in pregnancy is, if anything, even more grossly exaggerated. There are a lot of problems in modern obstetrics, and the outrageous C-section rate is indicative of this, but these are not lifestyle issues and these are not the fault of obstetricians.

Saturday, March 25, 2006

Bed rest part 2

I think that this op-ed really bothered me because Bilston is the nightmare of every compassionate doctor. You take the time to explain your recommendation, your reasoning behind it, the evidence that may or may not support it, trying to give the patient all the tools she needs to be an informed "consumer" of health care. Nonethless, Bilston insists that the doctor somehow forced her to go on bedrest even though he secretly knew that it wouldn't help.

The doctor did eveything a good doctor is supposed to do and now he's reading about himself in a whiny op-ed in the NYTimes.

If you want to be a "consumer" of health care, you MUST take responsibility for your decisions. The doctor virtually told her that he felt that he had no choice (from a medico-legal point of view), but to recommend bed test, even though he did not believe that it would work. It was Bilston's decision to follow the medico-legal recommendation instead of the doctor's personal views.

Friday, March 24, 2006

Bed rest

What is going on over at the NYTimes? There is an article on today’s op-ed page about bed rest for obstetrical complications. I can only hope that it was published because the author is related to someone at the Times, because it certainly doesn’t belong there. It isn’t news and it is a hit below the belt to obstetricians who try their best to help patients make decisions.

Bilston whines that her doctor recommended bed rest despite the lack of evidence for its effectiveness. That bed rest is not proven to be helpful is hardly a newsflash to obstetricians. The author unwittingly demonstrates why the doctor was afraid not to recommend bed rest; in the patient’s mind, the doctor was damned if he did and damned if he didn’t. Bilston is mad at the doctor because he recommended bed rest, but had he not recommended it, and something went wrong, she would have been the first person to blame him (and sue him) for not recommending it.

Bilston’s language is revealing: “I was placed on bed rest”. No, no one placed her on bedrest; she chose to accept a recommendation for bed rest. Bilston acts like the doctor tied her into bed, that once the doctor mentioned bed rest, she had no choice but to embrace it. That is absurd. The doctor himself told Bilston that he doubted it would be helpful and that there is no scientific evidence that it would work. On that basis alone, the patient could have chosen to forgo or modify the recommendation. She wouldn’t, though, because she didn’t want to miss even a tiny chance that bed rest might be helpful. Even so, she condemns the doctor for following precisely the same course. He recommended bed rest because he didn’t want to miss even the tiny chance that bed rest might be helpful.

Furthermore, Bilston easily could have gotten a second opinion. She could have consulted another obstetrician or, better yet, a perinatologist. Then she could have weighed the additional information in making her choice about bed rest. She didn’t want to make a choice; she wanted to blindly follow the recommendation of the doctor and condemn the recommendation at the very same time.

Bilston illustrates one of the biggest problems in the doctor patient relationship. The same patient who insists that she is a consumer of health care, entitled to all information and to control of medical decisions unconsciously views the doctor patient relationship in parent-child terms and acts accordingly. She’s mad at her doctor as if he were her daddy; he gave her the “wrong” advice and she was forced to follow it. Well, the doctor is not her daddy, and she is not a child. If she didn’t believe or didn’t like the doctor’s medical advice, she was free to ignore it or to seek another medical opinion. She didn’t do either, though, because the one thing she surely wanted to avoid was taking responsibility for own medical care.

Thursday, March 23, 2006

Three health care systems

On Asymmetrical Information, Jane Galt has started a discussion about controlling health care costs. Comments have included the usual arguments about "socialized medicine" vs. "free markets", but as the commenter Jessica points out:

"The twin elephants in the room that no one wants to discuss are 1) rationing and 2) end of life care."

These issues are probably the most important issues in cost control. Wrestling with these issues, indeed confronting any issues in health care financing requires recognizing that there are really three health care systems:

1. well care involving regular office visits, screening tests, preventive care, etc.

2 catastrophic care: auto accidents, inherited diseases, cancer

3. end of life care: care for people who have no hope of recovering. For example, senile dementia never gets better; it only gets worse. Providing complex medical care to these patients is extraordinarily expensive.

In the well care health system, needs are predictable and limited. A variety of financing systems would work and markets can operate as envisioned.

The catastrophic health care system has predictable needs (how many will have accidents, how many will get cancer), but the costs are astronomical and rising all the time. This is where health insurance really operates like insurance, however. Anyone could be struck by these problems, virtually no one could pay out of pocket and all of us want to be protected. The problem here is that new technology is extremely expensive, and there is essentially no limit as to what the costs might be. Even so, parameters could be developed to control costs. We could make a decision as a society that there is a limit to how much money we are willing to spend to save one person.

In the third healthcare system, though, all bets are off. The cost of this system is staggering and growing by leaps and bounds. No one gets better, extraordinary amounts of healthcare resources are diverted and essentially no value is provided. Billions of dollars are spent simply making hearts beat and lungs function.

It is this third healthcare system that is bankrupting us and fixing it will require rationing care. In other words, we have to draw the line beyond which we will not continue to spend money. It isn't "end of life" care per se; it is "prolongation of life" care beyond the point where there is any hope of recovery. There are those whose religious beliefs compel vitalism, a philosophy that any human life is worth extending at any costs. Those religious institutions could offer that care if they wished to do so; society as a whole should not be paying for this care and should not be diverting resources from the young to the dying elderly.

Wednesday, March 22, 2006

Seven Minute Visits

In today's NYTimes, The Doctor Will See You Now for Exactly Seven Minutes.

You may think that this is exaggeration, but I was briefly a part of a practice that literally had a 7 minute limit on patient visits. If I did not leave a patient room after 7 minutes, the office staff was instructed to page me out. Needless to say, I could not tolerate the practice for long and left after a few months.

Tuesday, March 21, 2006

Single Payer, Justice and Rawls

Ever notice how the opponents of single payer health care all have health insurance? Not just any health insurance, either. Most of them have excellent health insurance, the $5 co-pay for your brain surgery health insurance. I suspect that this renders their opposition more than a bit cynical. After all, if your personal situation is not going to be improved by a change in health care financing, and may even be worsened, it is difficult to look objectively at the various proposals.

Health care is a justice issue. I don’t mean justice in the legal sense, but in the moral sense. How are we to distribute the benefits and burdens of society in a just manner? The benefits and burdens in this case being health vs. illness, access vs. no access, and paying for your own care vs. paying for someone else’s care. At the risk of mangling the philosophy of the greatest political philosopher of our time, John Rawls, I’d like to invoke his philosophy in the health care financing debate.

Rawls famously described the “original position” as the starting point for creating a just political system. In the original position, people do not know where they stand in society; they do not know their race, sex or religious preference; they do not know if they are rich or poor. It is only by starting from this “veiled” position that people can create a political system that fairly distributes the benefits and burdens of society. For example, if you do not know if you are Black, you are hardly likely to create laws that discriminate against African-Americans.

Similarly, the health care financing debate should start from an “original position”. What health care financing system would we create if we did not know whether we had health insurance or not. I daresay that opponents of single payer would be rethinking their opposition if they did not know if they were to learn that they were about to permanently lose their health insurance.

A mathematician looks at health care

Adventures in Applied Math offers a mathematical perspective on the conflicting goals of health care financing in an article about Pareto-Optimal Healthcare.

Grand Rounds

Grand Rounds, the best of this week's medical blogging is on Healthy Concerns.

Sunday, March 19, 2006

The doctor patient relationship

From an outstanding post on Cancerdoc's website:

I think one thing that must be emphasized more than anything in medical education is the singular importance of the powerful, almost sacred relationship between doctor and patient. Like any relationship, it is trust that is the most critical, not all the bells and whistles.

Thursday, March 16, 2006

Concierge medical practices

I don't know what the solution to our healthcare crisis is, but I know that banning concierge medical practices is not part of the answer.

Frank Pasquale on Concurring Opinions comes down heavily against practices that charge patients a retainer for what essentially amounts to better healthcare than that tolerated and encouraged by managed care.

My response:

The rise of concierge medical practices is a direct result of the managed care revolution. A significant amount of healthcare dollars have been transferred from providers to administrators. The administrators have produced no improvement in the cost or delivery of healthcare.

In the meantime, doctors have been forced to see more patients in less time than ever before, in order to maintain an income level comensurate with their level of education. You can debate all you want about the appropriate income level for a physician, but the fact is that physicians are going to expect to make the same amount of money as their law school and business school educated peers. Anything else will simply cause the best physicians to leave the practice of medicine (which is already happening).

The managed care revolution encouraged doctors to behave like business people, and so they have. The obvious business solution for a doctor is to escape the bondage of self-enriching insurance companies and strike out on their own. At the same time, they can give their patients the time and attention that patients expect and deserve.

To claim that doctors not be allowed to open concierge practices is tantamount to saying that doctors must remain in thrall to insurance companies, institutions that do not have anyone's health at heart.

If you want to obviate the need for concierge practices, restore doctor's compensation for visits and procedures to previous levels (corrected for inflation). Both doctors and patients will be happier. The cost of healthcare won't need to rise to compensate, because the money can be taken directly from the administrators who add no value and suck up cash.


Wednesday, March 15, 2006

Medical Mistakes

Fat Doctor writes about a medical mistake:

His first push of the PCA pump button delivered a lethal dose of narcotic. Thankfully, he was resuscitated and after a long sleep in the ICU he is recovering well. [His wife] wrote, "We don't want to sue or anything, but we wish we knew what happened…"

… This family's surgeon immediately told Friend about the PCA problem and she easily accepted it as an accident. Now, to complete the process, they need to tell her how the incident report was handled and what was discovered during the investigation. Then she can rest easy, knowing the problem has been addressed and will be less likely to affect another patient next week.

That’s the way a mistake should be handled. I can tell you how it shouldn’t be handled:

Sixteen years ago, my father, a non-smoker, was diagnosed with a large mediastinal mass. I accompanied him to the thoracic surgeon (at the hospital where I was an attending) and my father expressed surprise that he could have such a large mass when a chest X-ray 8 months earlier had been normal. The thoracic surgeon explained that these lesions could grow very quickly.

Curious, I went the next morning and pulled the film. It had been a pre-op chest X-ray prior to cystoscopy for bladder stones. I was horrified to discover that the mass was in the original film. It was tiny then, but it had been picked up by the radiologist and read as lymphangitic spread of unknown primary. I called my father’s internist and was even more shocked to discover that he knew; the thoracic surgeon had known also before he calmly lied to my father. The doctors had decided among themselves that it would be “better for his morale” if they kept the truth from him. It had been an “administrative” error. The radiologist had never called the urology attending and the urology attending had never looked at the chart.

I gave them no choice. I told the internist that if he did not tell my father, I would tell him. He reluctantly shared the truth with my father, but the damage was done. Not just the medical damage; my father died 8 weeks to the day from the diagnosis, after failing to respond to a variety of treatments. The emotional damage was almost as bad because he could no longer trust the doctor who had cared for him for many years, just when he needed to be able to trust his doctor most.

No one ever apologized to him or to me. Needless to say, my mother sued, but that is a story for another post.

Monday, March 13, 2006

Pain in the ER

Doctors witness a lot of unavoidable pain. Whether it’s from trauma, from surgery or from labor, we become sensitized to it. We couldn’t be good doctors if we were not. Yet sometimes we become so used to the pain of others that we do not take the easy steps that would reduce avoidable pain.

When my son teenage son broke his arm in a snowboarding accident, I knew what to expect in the emergency room and I girded myself for a battle over pain medication.

My son is a big, strong kid with a high tolerance for pain. On the drive to the hospital, he appeared to be in agony, and no wonder. His shoulder was swollen to twice normal size. Either his upper humerus was broken or his shoulder was dislocated.

When he was taken into a treatment room for examination, I introduced myself to the nurse and told her I was a physician. I requested that my son receive pain medication before he was examined, and was informed in no uncertain terms the hospital policy was that patients could not receive pain medication until after X-rays were done. I was adamant though, so the nurse returned with the ER attending.

The ER attending also told me about the hospital policy. As a physician, I am aware of drug seeking behavior, but when a physical exam tells you that a patient is in legitimate pain, there is no need for X-ray confirmation. The ER attending did not have any doubt that may son had a significant injury. Fortunately, he was amenable to the reasonable suggestion that since we already knew he was injured, it would be quite appropriate to treat his pain. My son went to radiology feeling more comfortable. The X-ray showed a displaced fracture of the surgical neck of the humerus. The distal part of the bone was riding more than 1 cm above the proximal portion. Subsequently it turned out that the distal part of the bone had punctured the deltoid muscle.

Because I am a physician, because I insisted on speaking to the ER attending, and because I insisted on pain medication, my son received a painkiller immediately. Another child would have had to wait at least an hour for relief. How have we gotten to the point that the ER personnel feel free to disregard a patient’s pain until they have an X-ray to look at? Allowing the nursing staff to make an assessment of the patient’s pain would cost no additional time and no additional money. Isn’t it the least that we can do for the patients we treat?

Saturday, March 11, 2006

Office Scheduling

Over on Mad About Medicine, Dr. Kirschenbaum responds to writer complaints about office scheduling:
The reality is that dependent upon the day I can schedule an office day with all intentions of being on time and the first patient comes to me with cancer in the pelvis and I have to discuss complete removal of half of the pelvis. This is not a 15 minute visit and can even be a 1 hour discussion.

The issue of waiting is symptomatic of what is wrong with the prevailing culture in medicine. Like most doctors, I was trained with the same attitude: the beginning and end of my obligation to the patient was to intend to be on time. Therefore, a patient should not be angry if I wasn't on time.

Intention, though, is not enough. No doctor doubt thats simply intending to cure a patient is acceptable. We recognize that it is our responsibility as physicians to be knowledgeable enough to apply the appropriate techniques, medications, etc. to actually treat and hopefully cure the patient.

Similarly, it is not enough to intend to be on time, if we are not knowledgeable about whether our intentions are realistic. If, in actual practice, a doctor is never on time, he or she is scheduling patient appointments inappropriately.

There is a tendency among doctors to believe that "the system" is the way it is because it has to be that way. However, scheduling is not some sort of willy-nilly process that cannot take into account the realities of a doctor's life. It is possible to look at a practice and figure out just how often each day or week a particular doctor has patients that require more time than originally scheduled and build that time into the appointment schedule.

Just by way of example: if examining a doctor's practice reveals that on average he sees a patient a day with an unanticipated complication that eats up an extra hour, then he can build an extra hour into the schedule when there are no appointments.

Yes, yes, yes, I am aware that this lowers income. However, if a doctor is finishing each and every day 1-2 hours behind, the reality is that he is overscheduling for his benefit and to the detriment of the patients.

The unfortunate fact is that most doctors don't know how long the average patient waits, and if you don't know, you can't fix it.

Sometimes the Little Things Mean Alot

Many times the problem is not that healthcare providers individually treat patients poorly. It is that healthcare providers routinely tolerate a culture that is harmful to patients, without ever considering how this is impacting the patients.

Take hospital noise, for example.

When my son was hospitalized, my husband and I took turns staying each night for the 8 nights he was hospitalized. It’s not like I never slept in a hospital before; as an obstetrician, I can’t even count the nights I have spent sleeping in hospital call rooms. I have slept in very few patient rooms though and I could not believe the noise. The ambient noise level was not so bad, but the repeated intercom announcements, the banging of equipment and the nurses talking to patients and each other was unbelievable. Every one knew the patients were asleep, they just didn’t act like they knew or they cared.

Each nurse carried a cell phone/pager. She could be reached by anyone in the hospital and that included her own nurses’ station. Nonetheless, the nurses regularly called each other over the intercom system for routine matters such as help moving a patient. It was loud, it was unnecessary, and none of the nurses seemed to care, even when I asked about it.

I’m not alone in my ire, of course. Susan Mazer, MA, in an article entitled Curing the Noise Epidemic, points out:

Why do patients complain about noise? Next to the requisite hospital annoyances and discomfort, noise is experienced as unnecessary neglect serving no good purpose (my emphasis). It disturbs patients’ sleep, increases their anxiety, and puts into question basic consideration on the part of the hospital in general. The increased noise-induced stress is contagious, impacting the attendant family member who eventually winds up at the nurses’ station complaining about a variety of issues, each worsened by extraneous noise.
This could be easily fixed, if anyone cared to do it. This nursing administration of the hospital should prohibit use of the intercom system at night. The only possible exception might be for a code, but if everyone is carrying pagers, the pagers can be configured to page multiple people with one request in emergency situations.

Why is this still happening?

Thursday, March 09, 2006

More nasty comments

More nasty comments over on Kevin MD.

Here's my reply:

Judging by the vehement response, I have clearly touched a nerve. It is precisely this defense of the indefensible that is responsible for a great deal of the misery in the current health care system.

Time management experts agree that hospitals (including ERs) are run in a grossly ineffiecient manner. Quoting from The Boston Globe:

"Boston Medical Center, the city's safety net hospital, is becoming a model of how to bring relief to the nation's beleaguered emergency rooms, reducing treatment delays and closures to ambulances when ERs are more crowded than ever. BMC emergency doctors are treating more patients than they did last year and have reduced average time in the waiting room from 60 minutes to 40 minutes.

The secret lies in a radical idea for medicine, but one that has guided airport managers and restaurant hostesses for years: Keep the customers moving.

Urged on by a Boston University consultant, the hospital is eliminating obstacles that force patients to needlessly remain in the ER. It is cleaning up empty hospital rooms faster and rescheduling elective surgeries so surgery patients don't take up beds that emergency patients need.

Meanwhile, ER nurses stationed in the waiting area assess a patient's condition within minutes of arrival and then use a color-coded chart to track how long patients have been waiting."
So it's pretty obvious that there is lots of room for improvement in the delivery of care in the ER.

The topic of my blog has made some of you angry; you may not have noticed the subtitle: A Doctor's Plea to the Healthcare Profession.

So here's my plea to you:

Open your mind to the possibility that there is room for improvement in the miserable state of healthcare delivery. Consider how you, your office and your hospital might be part of that process. I'm not talking about doing more than what you do; I'm talking about pushing for efficiency and common courtesy. Most of all I am talking about opening your eyes to the misery all around you and realizing that you have the responsibility to improve the delivery of care.

She wouldn't have gotten in at my hospital in 7 hours

I posted a comment on Kevin MD about practicing defensive medicine and included a link to this blog. In case I had any doubts about the existence of arrogant doctors who don't care how long patients wait, I got this is response:

OMG, you're right! Tuteur's entire Blog rails against ER's. She wouldn't even have gotten in from the waiting room at my hospital in the 7 hours it took for her sons' care to be screwed up in her story ...
I don't get it. The writer (presumably a doctor) is so sure that this is acceptable that he is practically crowing about it.

For the record, I am very proud of being a doctor, and very proud of the scientific advances of our profession that have saved countless lives. I am quite sure, though, that none of our skill and sacrifice justifies treating patients arrogantly. Our job does not begin and end with treating a medical problem successfully. It matters how long people have to wait to see us. It really matters and we should be aware of it. That doesn't mean that we will always be able to see patients in a timely manner, but it does mean that we shouldn't believe that we can take as long as we damn well please and if they don't like it, they can go elsewhere.

Anyone who has ever been a patient knows this, but many doctors have not yet been patients. So for them, I have a suggestion:

The next time you are in the ER, head out to the waiting room and pick out a patient who looks like it could be you; not someone who came in for a frivolous reason, but someone who came in for a problem that can only be dealt with in the ER, maybe a bowel obstruction from end stage ovarian cancer, for example, or a patient dehydrated from being unable to tolerate chemo. Glance at the chart to find out when the patient came in and every so often check the chart to find out how long the patient ultimately waits for care. Then ask yourself, if there is a good medical reason that the patient has waited so long. Would you, as a physician, deem such a wait to be reasonable if that suffering patient was you or your spouse? I bet you'll be surprised at what you find.

Wednesday, March 08, 2006

How long do your patients wait?

What never ceases to amaze me is how much of the inconvenience that doctors perpetrate on patients is purely gratuitous. The patient isn’t kept waiting because the doctor has an emergency or the office schedule is over booked. The doctor keeps the patient waiting simply because he can.

I have seen many examples of this, but the most egregious happened to my husband several years ago. My husband has a long history of recurrent occipital neuralgia. He has seen a variety of specialists for this with uneven results. A neurosurgeon of our acquaintance recommended yet another neurologist, this one a specialist in neuralgias. My husband made the first appointment of the day, since he needed to get to his law office as soon as possible. When we arrived at the office, the secretary told us that the doctor was not there and she didn’t know where he was.

We proceeded to wait for almost an hour after the scheduled appointment time, my husband becoming angrier by the minute. After about 20 minutes, I stepped into the hall to investigate. Much to my surprise, I saw the doctor in the back office, flirting with one of his employees. Nonetheless, the secretary at the front desk told me that the doctor was “busy” and would be in soon.

I went back to my husband and told him what was going on and what was likely to happen. I predicted that the neurologist would come in eventually and announce that he had been detained with an emergency. That’s precisely what happened. The neurologist eventually appeared and lied without the slightest qualm. He had been in the ER for the last hour, he said, and was sorry to be late.

Why did the doctor do this? The short answer is “because he could”. Who, after all, was going to stop him? The longer explanation is that most doctors give no thought to the way they inconvenience their patients. It never even crosses their mind that a patient may have important obligations of his own. The doctor is going to be there for the next 12 hours or more, so it makes no difference whether he sees the patient at the appointed time, or at his own convenience.

For those who run an office practice, do you know how long the average patient waits to see you? Would you wait for another professional for as long as your patients wait for you? What, after all is a reasonable time to wait: 15 minutes, 30 minutes, an hour?

It is simply a matter of respect to be aware of how long your patients are waiting and to do everything possible to minimize that wait.

Tuesday, March 07, 2006

What would happen in the ER if ...?

Following up on the previous post, what do you think would happen if patients began demanding some accountability from the emergency room staff? Suppose patients came in with a form that the triage staff would fill out. It would begin something like this:

I am visiting the ER because of: (chief complaint)
The reasonable amount of time I can expect to wait to see a doctor is:
The name of the doctor I will see is:
How many patients does the doctor need to see before me:
The doctor ultimately responsible for my care in this ER is:

It would also include the following qualifier:

I am aware that there are other patients in the ER and that the staff is busy and shorthanded, but this is NOT my responsibility and I should not suffer for it.

Sunday, March 05, 2006

Waiting in the ER

One day last year I spent 7 hours waiting with my son in the emergency room of the premier children’s hospital. It wait was medically irresponsible and administratively unnecessary. It was emblematic of the lack of respect shown by doctors to patients.

My son had badly fractured his humerus 10 days earlier. He had had surgery and was left with two K wires protruding from his arm. The previous day he had spiked a fever and was seen to have pus leaking from the K wire tracts. He should have been admitted then (that is a story for another post), but was sent home on oral antibiotics.

I brought him back to the hospital with a fever of 102.5 and shaking chills. I knew precisely what was wrong (he was septic from his infected arm) and precisely what was needed (admission and IV antibiotics). I spoke to the admitting orthopedic resident and told him we were coming and what we needed.

What should have happened? We should have been taken to an examining room when we arrived and the orthopedic resident should have been paged. After a brief exam by the orthopedic resident, he should have been started on IV antibiotics. Either the resident or the attending on call should have pulled the K wires and he should have been sent to the floor. In all, this should have, and could have, taken an hour at most.

What actually happened? When we arrived, my son was given Tylenol by the triage nurse and told that he would be seen shortly since the ER was not busy, but:

We waited 2 hours in the lobby before being taken into a room.
We were seen by the medical intern in the ER who agreed with diagnosis and treatment.
We waited an hour to be seen by the medical attending in the ER who also agreed.
We waited an hour to be seen by the ortho resident who agreed with diagnosis and treatment, then disappeared.
After 5 hours, my son had received no treatment, not even additional Tylenol.

Then I got angry and demanded to see the ortho resident immediately:

I demanded that the ortho resident start IV antibiotics immediately before doing anything else. She complied and called the ortho attending on call.
The ortho attending appeared and was appalled at the state of my son’s arm. He pulled the K wires.
We waited an additional hour to be transferred to the floor.

Ironically, various members of the ER staff repeatedly apologized to us for the wait. Amazingly, they did not seem to understand that we were waiting because of them. I was repeatedly struck by the fact that the staff viewed the wait as one might view bad weather: unfortunate, but not under their control. It was taken for granted that if you come to the ER, you must expect to give up your entire day to be seen and treated at the pleasure of the hospital staff.

Where did this attitude come from? Why do we believe that people who come to the ER can’t expect to be seen in a timely fashion? Why do we expect that sick and injured people should be expected to sit until we are good and ready to see them, are not entitled to know how long they will wait, or who they are waiting for? None of this would ever countenance this behavior from any other professional and the fact is that when we, as physicians, seek medical care, we don’t expect this behavior from other physicians.

A respectful approach to patient care in the emergency room would require:

Notifying the patient of the anticipated wait.
Updating the waiting time if it changes.
Explaining how many patients must be seen ahead of time.
Notifying the patient which doctor he is waiting for and the education level of the doctor.

None of this requires any additional time or money. Failing to do this does not satisfy any medical or administrative reason. All of this is simply a matter of treating patients with respect. Why don’t we do it?

Welcome

The medical system in this country is broken. There is not a doctor in the United States today who does not believe that this is so. Beset on all sides with increasing demands and decreasing resources, the practice of medicine has become grim indeed. Pressured by increasing paperwork and productivity requirements, decreasing reimbursements and a fixed number of hours in the day, doctors are struggling to provide quality care.

There is another fundamental way in which the American medical system is broken, however, and that way is completely under the control of physicians. The American medical system no longer treats patients with respect. Patients are routinely forced to wait absurd amounts of time in emergency rooms and doctor’s offices. They receive inadequate information about illnesses, and precious little information about alternative medical options. Patients in pain are routinely under treated, forced to wait, and to beg for adequate pain medication.

In a way, this is not surprising. Patient comfort has never been a priority in the delivery of medical care. During my internship and residency some 20 odd years ago, I was yelled at every day and in every way by my superiors. I was chastised for a million reasons, large and small, important and petty. Yet I was never yelled at for the way I treated the patients.

I tried my best to treat patients respectfully, but it didn’t matter if I did so or not. No one cared how the patients were treated as long as I, personally, didn’t kill them. I could wake them whenever I wanted, make them wait for me for as long as I wanted, and treat them inadequately for pain. No one else was the least bit concerned.

As outside pressures on the medical system have mounted, the situation has only gotten worse. The fact is, though, that it is entirely within the power of doctors to change this situation. It does not cost time or money to treat patients with respect. It only requires making it a priority for each of us individually and for the profession as a whole.

This will require a change in attitude though and medicine is not noted for its willingness to change. The most profound change in attitude in the profession comes from within my own specialty, obstetrics. Fifty years ago, women routinely gave birth in stirrups, over medicated and without husbands at their sides. This has completely changed. What happened?

Traditional obstetric practice was never medically necessary. When women began requesting changes, doctors reflexively refused. Yet as more women continued to ask, doctors began to wonder why they were refusing. There was no reason not to let husbands in the delivery room, for example; doctors could not justify it to themselves and so they relented. The process of birth was enhanced for everyone: mothers, fathers and physicians themselves.

The purpose of this blog is to raise the same kinds of questions. Why do we treat the patients the way we do? Is it justified? And if not, how are we, as physicians, going to change?