Musings

2010-07-07T23:39:00.002-05:00

RUDE AND POMPOUS

"not sure how he made it through med school since his head is so big. I was never treated so rudley. I also was spoken doen to as if i was illiterate or dumb. I would never reccommend him and I plan to make a formal complaint regarding his poor communication and derogative nature."

I have not been to the dentist in 2 years. As the first year of fellowship was finishing up, I thought that now would be a good time to make a trip. My insurance company informed me that I was assigned to a certain dentist close to my home. Not knowing if she was any good, I decided to Google her and to my horror saw several negative reviews. Without a second thought, I called my insurance company and changed providers. Of course, now I have to wait one month for the change to go into effect before I can see my new dentist.

Soon after making this change, I figured, why not see if any of my own patients have reviewed me. Only one had. His/her review is posted on Vitals.com. You can read what he/she had to say about me above.

Humbling.

I went back and reread a previous post I had written on what it means to be a good doctor.

I seem to have forgotten my own advice.

2010-04-01T21:50:00.002-05:00

The Games We Play

I have criticized hospitals, patients, and insurance companies in my prior diatribes against our current health care system. Now, its time to take on physicians. What are we doing incorrectly? What are the games we play?

Our current health care system emphasizes specialization but as a byproduct it breeds laziness. It promotes waste and inefficiency. And physicians profit from this.

Lets say a surgeon is paid $5,000 for a gallbladder operation. The patient and the insurance company aren't paying the surgeon $5000 just to take out a piece of tissue. They are paying the surgeon to do a procedure and make sure the patient does well. This involves making sure the post-op course and well as the intra-op course are uneventful. However, here is what really happens. The surgeon pockets the $5,000 but before he does that he gets a primary care physician to see the patient prior to the surgery and get him tuned by doing all the pre-operation work. He removes the gallbladder but the operation is complicated by significant blood loss. Afterwards he forgets to make sure the patient's regular home medicines are ordered correctly. After the surgery, he consults medicine, renal, and cardiology to help him manage the patient post operation. This basically involves making sure the mistakes he made are managed. The surgeon sees the patient the day after surgery and then ignores the patient for the rest of the hospitalization.

Meanwhile, the renal, cardiology, and general medicine teams all bill the patient for their time, when in fact all they did was make sure the patient's chronic medical problems weren't worsened by the surgeons incompetence.

Its a win win for the medical system and the physicians. Everyone bills the patient separately for the same job. Lets examine this with an airplane analogy. You pay $500 to fly to Paris. When you get your credit card bill you find out that the pilot charged you $500 for taking off and then a separate pilot charged you $500 to land the plane. The stewardess charged you $50 to bring you those little bags of peanuts. By the way, those little bags of peanuts also ended up costing you $100. Total cost: A Total ripoff!

How about a new model for physician compensation for inpatient care. The surgeon gets paid $6000. However, this is the total amount that a patient or the insurance company will pay the hospital. If the surgeon wants a consult to help him manage the patient, he has to pay out of this total lump sum. So, if he wants a renal, cardiology, and general medicine consult because he forgot everything he learned in medical school, his total take home pay is less. But the patient pays one time for one procedure.

By the way, good luck getting your hand on any of the primary billing data for any hospital. That stuff is guarded like it is a national secret. No hospital will make public exactly how much profit it makes on individual procedures. Trust me, I've asked. Even I can't find out how much the things I am doing are costing the patient or how much profit I am making the medical system.

http://www.youtube.com/watch?v=xskFo75Wdhs

2009-08-20T19:17:00.006-05:00

You Get What You Pay For

The healthcare reform debate continues to unfold and the arguments for and against reform are both full of contradictions. I can't help but think that a few years/decades from now, we'll look back and not believe we let this travesty unfold. In my effort to shed some light on the issue, I've put forth some of the arguments I hear the pundits making and my own rebuttals.

Arguments Against Reform:

We don't want bureaucrats involved in health care.

My reply: Guess what? Your access to health care is already controlled by someone in a far away location that knows nothing more about you than a few notes on his computer screen. Screeners for health insurance companies dictate who gets health care and what kind of care they get. Even with the best insurance plans, there are severe limitations on what kind of tests and drugs people have access to. For you to get your MRI or the newest drug, your physician and/or you end up spending hours on the phone with an insurance representative getting prior authorization. A recent study estimated that the paperwork required by insurance companies costs us $31 billion/year, or roughly 7% of all US spending on physician services.

Why is this fact so little publicized? If this is the case, why are so many people happy with the healthcare that they currently get? The reason most people are happy with their health insurance is because most people are healthy! Take a poll of the chronically ill and you'll get a much different viewpoint. I like to think of our current batch of insurance companies as highly paid backup quarterbacks. They are great and everyone loves them until they actually need them. When forced to utilize their services we quickly find out their extreme limitations. And of course, they are paid too much for doing absolutely nothing.

This is socialism! I hate socialism! The government needs to leave healthcare alone!

A national healthcare plan is no different that having public schools! Is that socialism? Is the fact that our current education system allows for public and private schools some left wing conspiracy? How is universal access to healthcare any different? The current plans allow you to participate in the public plan or pay more for the private plan. Sounds very similar to our school systems to me. And just like education, healthcare should be something that we should try to make available to everyone.

However, we should take a minute to examine the school analogy. The reason so many of our public schools are so horrible is because they are grossly underfunded. If we want the national healthcare plan to work, we have to be willing to spend more money.

We don't have the money to spend! It will cost TOO much!

Apparently we have enough money to spend to pay for new cars for people that don't need new cars! We have enough money to rescue failing banks. And my personal favorite, we have enough money to go oversees and kill a bunch of terrorists. What do you think kills more Americans? Terrorists or lack of health care? There are people dying everyday in your very city that can't afford the care they need and we don't want to spend money to help them. But if there is even a hint of a foreign threat that might endanger American lives, we're willing to spend whatever it takes to buy the latest bombs and planes. The VERY people against spending for healthcare due to financial concerns seem to be the people that would consider cutting back spending for our armed forces to be anathema. Confusing to say the least.

Arguments FOR Reform:

We don't have enough money!

My reply: The money argument is used by both sides of the healthcare debate. The people for health care reform envision cost savings by enforcing quality measures, regulating the types of procedures covered, and removing the profit motive. Another word for "Regulating the types of procedures covered" is rationing. It is true, that rationing in some form is already prevalent in the current health care system and in all aspects of life. If you don't believe me, take a look out on the street. Everyone isn't driving a Rolls Royce. If you wanted to get expensive procedures or drugs with the current healthcare plans, you would have to jump through many loopholes to qualify. This is rationing. Also, the current health care plans don't cover 45 million people. This is rationing.

However, switching to another form of rationing wherein you cover everyone but offer less services to each person is not a step in the right direction. As I have said before, our healthcare system is the best in the world and it is this great healthcare system that we are afraid of losing. I don't think that the proponents of health care reform want everyone to have access to crappy healthcare. They want everyone to have access to the best healthcare.

There are three variables involved here:number of people covered, services offered to everyone who is covered, and the total cost to the system. If you increase the number of people covered and hold cost stable (or decrease cost) then you HAVE to limit the number of services you offer to everyone in the plan. If you try to increase the number of people covered and offer everyone the same services, then you HAVE to increase cost.

The only way to limit costs in a national health system is to limit the access to care for everyone. These people argue that we are spending too much and doing too many procedures. A great example is the often quoted fact that the city of Boston has more MRI machines that the country of Canada. I like to believe that this might be the reason that you have Canadians coming to Boston to get healthcare instead of Bostonians going to Canada. However, the quality of the healthcare being offered in the US is a discussion for another post.

The current system waste too much money on end of life care. We need to focus on prevention.

President Obama recently used the death of his grandmother to explain how the US healthcare system wastes money. He thinks we need to provide less aggressive end of life case and focus more on prevention.

I would love to see ONE study that shows that prevention works. The sad truth is that the US healthcare budget cannot spend more money on prevention that the combined budgets of Big Tobacco, McDonald's, Coke, Pepsi, and Twinkies (who makes these by the way?). Also, as good as we are at taking care of medical problems, we cannot instill in people a sense of personal responsibility. People are going to gravitate towards instant gratification. Until we change our culture (eating habits, exercise routine, and our expectations for what healthy means) we will continue to have problems with chronic diseases. You can't imagine how many conversations I have had with people that weigh 250-300 lbs that don't understand that they are fat! The reason for this is because the patient's brother, his wife, his wife's brother, and all extended family and friends are actually fatter than he is. To him, being 250lbs is actually too thin! Until we realize as a society that we have to take personal responsibility for our health, no amount of money spent on preventative measures will make a difference. If you don't believe me, take some time to examine our own President who is a strong proponent of the national health care system and of focusing on preventative measures. If preventative measures work, why is he still smoking? He is a walking, talking example of the failure of preventative measures.

I apologize for the rambling nature of this post. There is so much ground to cover and it is sometimes difficult to focus in on what to talk about first. As you might have gathered, I hate the current health care system but I also think the focus by the Democrats to limit health care spending by instituting a single payer system isn't the right way to go.

However, unlike the town hall hecklers and the insurance industry that have no better alternative to offer, I would like to propose an alternative. Here are some of my ideas of how to institute health care reform:

1) Everyone gets access to a basic level of healthcare.

2) People have the option to purchase private healthcare out of their own pocket. If they do this, the amount they spend on private health care should be tax deductible.

3) There is NO role for insurance companies. People buy healthcare directly from the provider. If they want private healthcare, they pay whatever the provider bills them.

4) All healthcare providers are graded/evaluated under a national system and these evaluations are easily accessible to the public. This ensures that people know where they can get "quality" care and thus they can function as knowledgeable customers. The current healthcare system hides the true cost of healthcare from the consumer (patient) and hides the quality of the product being bought. We are paying some unknown amount for a service/good whose quality we can't judge.

5) We limit malpractice monetary rewards levied against individual physicians but at the same time we leave uncapped the amount of damages sought against health care systems. This ensures that hospitals will take a much more proactive role in picking out the bad apples.

6) We increase taxes on things that make us unhealthy. We tax unhealthy foods and we increase the tax on tobacco and alcohol. At the same time, we offer tax credits for restaurants that offer healthy food options. As an example, if McDonald's wants to sell fries and not pay more taxes, they can offer more salads. These costs will likely just be passed to the consumer but that isn't a bad thing. If you want to eat Twinkies all day, you shouldn't expect your neighbor to pay for you heart surgery in 20 years.

7) We stop covering medical problems caused as a direct result of breaking the law. For example, if you had a stroke or a heart attack because you were smoking crack. Guess what? You better have the money to pay for you medical coverage because neither the government nor any insurance plan will be obligated to cover your medical expenses. If you drive drunk and get in a car accident, you foot the bill. This seems simple to me. Our current system will pay for you to get all the medical care you need if you are the drunk driver and end up in a car accident. But the poor people you almost killed who might not have insurance are on their own. A fantastic system.

I would love to hear your thoughts on what I have proposed. Thank you for reading.

2009-06-11T08:26:00.013-05:00

We Need To Spend more on Healthcare!

How much would you pay to spend one more year with your loved one? What is the value of knowing that if you get sick, you have the best medical care in the world right down the block? What is that peace of mind worth to you? Our country bemoans the cost of healthcare while sitting around a table eating KFC and McDonald's. Am I the only one who finds this just a little disingenuous. I maintain that our healthcare system is the best in the world and that it is a bargain. In fact, we should be paying more for the healthcare we get. I'd like to go over the biggest complaints against our healthcare system and hopefully explain why I feel so differently from the majority.

Widely held belief #1: Our healthcare system does not provide quality. In fact there are many countries that provide better care. The "I wish I lived in France or Canada complaint!"

The widely quoted studies that claim US healthcare quality isn't up to snuff do not take into account genetic and behavioural differences. For example, the incidence of coronary artery disease in the Japanese population is much less than that in the US. Do you think this is because we don't have good cardiac care or because we like eating at McDonald's?

Many commentators vilify the US for the fact that infant mortality in the US is higher than in many European countries. This sounds horrible until you look at the details and realize that many European countries only count infant deaths if the infant lives one month and then dies. Deaths in the first month aren't always included. Meanwhile in the US, all live births that end up dying count towards our statistics. Furthermore, we are much more aggressive with preterm births. The fact that our patient population is much sicker and we include all deaths in the statistics explains the gap in infant mortality.

While we'd love to think that the grass truly is greener across the border, lets take a closer look. In Canada you wait weeks, months, even years for procedures not deemed emergent like hip replacements. A set amount is allocated at the start of the year for each procedure and when the money runs out, so does any hope of you getting your procedure done that year. We aren't talking about breast implants and botox. I'm referring to procedures like knee and hip replacements so that grandma can walk again instead of spending another six months in a wheelchair popping narcotics to relieve the pain. Sounds like a great healthcare system.

Lets forget the fuzzy math and the unavoidable delays inherent in any system that rations healthcare. Ask yourself what you would do if your mom, dad, son, or daughter developed a serious medical condition. Would you take them to Canada, France, or Great Britain or would you take them to the top notch hospitals all across this country. Just to make the point further, one of the Canadian Parliament members who is a huge proponent of the Canadian healthcare system came to the US to get care when she developed cancer. People from all over the world fly into Boston and Baltimore in the hopes of having their disease treated. They don't fly to Paris for the healthcare.

Widely Held Belief #2: Even if we deliver good quality healthcare, it costs too much! This is the "I want to eat my cake and have it too!" complaint.

Healthcare does cost a lot of money but so does going oversees and killing Iraqis, so does giving subsidies to farmers, bankers, and auto workers, so does paying for your local NFL team to build a new stadium. Before saying that healthcare costs too much lets compare it to other expenses both at a national level and at a personal level. For every dollar in federal taxes, 41 cents was spent on war, preparing for future war, or paying off old wars (interest on the military portion of the national debt). 19 cents of the federal tax dollar was spent on healthcare. So, we spend twice as much money killing people as we do on helping our own citizens get the healthcare they need.

Oregon is one of the few states that has medical coverage for all its citizens. They have published their fee schedule that details reimbursement for all covered procedures. It makes for interesting reading. Lets go through it and try to compare how much Oregonians pay for various medical procedures and try to compare that to what else they could buy with the same amount of money.

Open chest heart massage: $110.67 or you could buy two tickets to watch the Portland Trailblazers (section 209, rows:a-h). Of course you'll have to pay extra for the parking and the food you eat at the game. So, a night out to watch a pretty bad NBA team vs open heart massage. Which one do you think costs too much?

Insertion of a pacemaker: $351.10. You could buy a Playstation 3 for $399. Of course you'll have to pay extra for any games you want to buy. So, the insertion of a device to keep your heart beating costs less than a Playstation 3 but we MUST be spending too much on healthcare, right?

Bone Marrow Transplant: $92.16. Or, you could spend one night at a Holiday Inn Express (20 miles outside Boston). This price doesn't include tax or any of those little drinks in the mini-bar.

Antibiotics for severe infections like pneumonia (zosyn): $5.57 per dose. Can you even get a meal at McDonald's for that much anymore?

Cesarean delivery: $1221.99 or about the same as a year's supply of diapers. This is a close call. What do you think should cost more?

The amounts quoted above might not jive with the amounts many of you see when you get you bill from the hospital. This is because a significant amount of money is skimmed off the top by insurance companies. Have you ever wondered why the tallest, newest buildings in many cities are owned by health insurance companies? While doctors, nurses, pharmacists, and drug companies offer something to the patient, I am at a loss for the value added role for insurance companies. The costs I listed above are what the hospital is actually reimbursed. A significant amount of a patient's total bill goes towards overhead and is lost due to inefficiency. This will be covered in another post where I discuss my dislike of insurance companies.

One other reason for the large healthcare costs in the US is due to the fact that we are the innovators for the rest of the world. The reason HIV drugs are available in Africa is because we spent the research dollars to develop them here for our citizens. The same can be said for ~ 90% of the medical breakthroughs over the last few decades. We develop the technologies and techniques that the rest of the world uses. Doctors and scientists from all over the world come here to learn and to help us further medical care. Innovation comes with cost.

My final point will probably be the most controversial one. Healthcare costs in the US are going up because we aren't taking care of ourselves. That's right, I am blaming the patient. We don't exercise, we eat too much, we drink too much, and we smoke. And then when we are 100lbs overweight and addicted to nicotine, we act surprised when we have a heart attack. When we get the hospital bill we get mad. We rant and rage and go on CNN and complain about how healthcare costs are ruining America. We now have the technology that allows you to live despite a lifetime of overindulgence but don't' expect that to be free. Everyday, you can scarf down your bag of Cheetos, chug a few cans of Budweiser, eat the box of Krispy Cream doughnuts, and take a long deep breath full of that great Marlboro air, and still live to see your grandkids have kids. Isn't America great? By the way, when you have that massive heart attack and go to the hospital to get your arteries opened up, the hospital will be paid $600 to place a stent in your heart. That is about the same as a person spends on cigarettes over a 4 month span. Do you still think we need to reduce health care costs?

I think everyone deserves quality health care despite their ability to pay for it. However, I think that a single payer system isn't the solution. And certainly, any healthcare reform that seeks to curtail healthcare spending is not going to result in better patient care. I'll discuss a few ideas in my next post but I would love to get your thoughts on healthcare spending.

2009-02-15T00:11:00.006-05:00

Specializing

A few decades ago the medical school curriculum committee was meeting to discuss updates to the standard curriculum. As they debated on what courses needed to be added/dropped they decided to ask Dr. James Kirklin (CT surgeon) what information was important for medical students to learn prior to graduating. Without hesitating he replied, "They should know it all."

I want to be a cardiologist. Specifically, I want to focus on heart failure. But not just heart failure; I want to be an expert on acute heart failure. And if I really get to do exactly what I want, I'd like to work on peripherally inserted mechanical support devices for acute heart failure.

My own career goals make what I am about to say that much harder to believe. I hate the current medical model that emphasizes super-specialization at the expense of a broad based knowledge base.

It used to be that the same doctor that diagnosed your heart attack could take out your gallbladder and deliver your baby. Understandably, as knowledge about the various medical fields (Surgery and Medicine) grew, practitioners started focusing in on either surgery or general medicine. As we learned more about the body, these fields further subdivided and now you had speciality training in various subdivisions of either medicine or surgery (cardiology, pulmonary, renal, etc... or GI surgery, cardio-thoracic surgery, etc...). However, as recently as the 1950s, physicians were still trained in both surgery and medicine. In fact, it wasn't until the 1960s-1970s that you had many specialities grow and develop their own specific training pathways. Up to this point, the growth towards specialization dovetailed nicely with and likely contributed towards the explosion in knowledge about the various specialities.

However, sometime between the 1970s and now, we started fracturing the medical landscape into smaller and smaller pieces. Some of this was a direct result of the exponential increase in knowledge. You had cardiologists becoming sub-specialists in heart failure, catherization, or electophysiology. We also started to self-segregate based on other, less clear factors. You had the start of ER and hospitalist medicine. If you just want to focus in on the acute management of all medical problems but did not want deal with any of the long term management or consequences, you could train to be an ER physician. Likewise, if you just wanted to manage inpatient medical issues, you could train to be a hospitalist. These new subdivisions were not directly linked to organ systems or disease processes, but rather to certain situations in health care delivery.

Let me offer an analogy comparing our health care system to flying an airplane. Initially all pilots could fly all airplanes as there weren't that many different kinds. As varying models were designed, pilots started to specialize in certain types of aircraft. The Cessna pilot and the 747 pilot became specialists in their own type of machinery. However, what you didn't see happen is the development of a pilot who specialized in takeoffs, and one that specialized in landings, and one that specialized in flying through hurricanes. What you didn't see is one pilot managing the airplane during takeoff and then openly admitting that he didn't know (or care to know) about how to continue to fly the plane and/or land it, and that that was someone else's responsibility. Add a healthy dose of poor communications between all involved parties to this super fragmented model and you have a great recipe for chaos. If you think such a system of flying airplanes would surely lead to mistakes and deaths, then welcome to our current health care system.

As we have developed this amazing, detailed knowledge base about the human body, physicians have gravitated towards the fields and opportunities that most interest them while at the same time paying lip service towards retaining the basic knowledge base about the field as a whole. Despite my desire to focus in on a very specific patient population, I ardently believe that my ability to offer good care will involve more than a detailed knowledge about a focused problem.

2008-05-20T09:02:00.004-05:00

Living or Dying?

Randy Pausch is a computer science professor at Carnegie Mellon. Carnegie Mellon's computer science department has a lecture series titled "The Last Lecture." The premise being that if this were your very last lecture, what would you talk about? They asked Dr. Pausch to give this years last lecture. While meant to be a fun and interesting interlude, this lecture took on much more significance when Randy learned that he had metastatic pancreatic cancer and this really would be his last lecture.

His talk was taped and posted on YouTube. You can watch it here. Over 2 million people have watched the video since it was posted.

Randy Pausch has a website where he posts frequent updates about his medical course. You can visit his website and find out how he is doing.

He even wrote a book titled The Last Lecture -- which you preview here. He did all this within the last year after finding out he had pancreatic cancer. Not bad.

2008-04-09T23:17:00.003-05:00

Hope Renewed...

Ms. F lived. She beat the odds. She was found unresponsive at home covered in her own feces, surrounded by flies and maggots. No one knew how long she had been in this state. She was having trouble breathing and was put on a breathing machine as she was transported to our emergency department. Her temperature on presentation was 94.0, her respiratory rate was 40, her heart rate was 130, and her blood pressure was 80/40. She was completely unresponsive, even to painful stimuli. She was bleeding from every orifice except her eyes and ears. Her labs on admission showed a white count of 2.0, a hemoglobin of 5.0, and a platelet count of 10. Her BUN was 255 and her Creatinine was 10! All of here electrolytes were abnormal.

She was infected, her mental status was horrible, she was having trouble maintaining an adequate blood pressure, she required the support of a breathing machine, her kidneys were shutting down, and she was bleeding profusely.

Ms. F has a history of multiple sclerosis and her only other hospitalization had been for renal failure secondary to a neurogenic bladder. It turns out that this time she had also been experiencing decreasing urine output over the prior week or two. She had difficulty urinating and toxins built up that resulted in altered mental status. A CT scan done the night she came in to the hospital showed that she had retained so much urine that she had perforated her bladder.

Ms. F was on a ventilator for ~ 15 days. She received 15 units of blood and platelets over the first 2-3 days she was in the MICU. She was treated with very broad spectrum antibiotics. She underwent bladder repair.

She lived. She left the hospital a few days ago. She has two little kids at home. I met one of them -- a wide-eyed seven year old who will probably never know how close he came to losing his mom.

When she first came into the hospital, I had no idea if she would live. I thought for sure that she would pass away. Her recovery speaks to the strength of youth and the remarkable ability of the MICU nurses to deliver fantastic care.

Cases like hers remind me of advice that one of my surgery attendings once gave me. We had just left a patient's room where he had discussed the pros and cons of getting lung surgery to remove a tumor. The patient had asked my attending how long he had to live. As we left the room, my attending turned to me and said "Never be arrogant enough to think you know how long a patient has. You will always be wrong! Anything you say is a guess... an educated guess but a guess nonetheless."

So much of what we do involves predicting mortality. When a patient asks if he should undergo surgery or when the family asks how likely it is that their loved one will get off of the ventilator, they are really asking what their chances of dying are... And I don't know.

Ms. F was the exception. The next 99 people who come in with her problems will probably die in the hospital within a few days. The question is, do we treat those other 99 people just as aggressively in the hope that they turn around like Ms. F did? Or, do we tell the family that the chances of recovery are so small that they should make the patient comfortable and not pursue aggressive treatment?

2008-02-24T10:50:00.006-05:00

The Last Day

I finished my MICU rotation yesterday. As I walked out I couldn't help but think of the failures I had, the people I wasn't able to help.

The 60 year old Boeing factory worker and father of four. He came in with profound hypoxia (unable to oxygenate his blood) and despite everything we did, we weren't able to improve his breathing. He was diagnosed with acute interstitial pneumonitis, a catch-all term that hides the fact that we don't know the cause or the cure. He was completely healthy prior to this hospitalization. He and his wife had been vacationing in San Diego just a few months prior. He died.

The 28 year old deaf/mute mother who had never been in the hospital other than to deliver her baby a few years prior. She also presented with shortness of breath and was soon put on a ventilator. It turns out that she had the flu and her lungs also had been infected with bacteria (staph aureus). We weren't able to help her breathing. She ended up going on the heart/lung bypass machine (ECMO) to give her one last shot. She died.

The 50 year old husband who presented with liver failure due to a disease known as primary sclerosing cholangitis (PSC). He had been on the liver transplant list until he developed an infection and was sent to the MICU. Based on verbal reports, they had actually found him a liver but just a few minutes/hours later, he became sicker, and they realized he had developed an infection. He was taken off the transplant list temporarily, started on antibiotics, and sent to the MICU. He never got a new liver. He was surrounded by family and friends. When I pronounced him dead, his mother looked at me and asked, "Thats it? Is he gone?" to which I could only nod yes. He died.

During my time in the MICU, I took a day off to go interview for cardiology fellowships. As I sat there through the interviews, with my interviewers telling me how impressed they were with everything I had done, I couldn't stop thinking about all the people that I had taken care of the last few weeks that hadn't made it. Its easy to tell myself I did my best and that these people probably wouldn't have made it anyway, but that excuse rings false. I don't like failure -- its a selfish feeling. I want to be better. I don't want my patients to die.

2008-02-06T13:34:00.000-05:00

"Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door"
-- from "The New Colossus" by Emma Lazarus (on pedestal of The Statue of Liberty)

I love the intensive care unit. I like taking care of the sickest of the sick. I like working through the pathology, trying to understand the physiology, and utilizing everything science has to offer to give these incredibly sick patients one more shot.

By the time a patient gets into the MICU, they are on death's door. They might be infected, be bleeding, unable to breath, and have trouble maintaining a normal blood pressure -- the sickest might have all of these. We hoist them onto their ICU beds, we remove their clothes, we attach numerous monitors. If they are agitated, we sedate them. We stick them in theirs arms, their legs, their necks, and their chest. We place tubes down their throats, up their rectum, and in their urethra. We give them drugs that have horrible side effects. If their hearts stop beating, we pound on their chest, shock their heart, and give them more drugs. And yet, I love the intensive care unit.

Most of these patients don't live very long. Despite everything we do to try to help, they frequently end up passing away. The mortality rate in our intensive care unit can approach 50%. And yet, despite the torture we put these patients through and despite the sobering final results, I love the intensive care unit.

Why? Why would I love working a place where I fail so much. Why would I want to put anyone through the things I have described above?

I can sum it up best with a quote from the Shawshank Redemption:

"Remember Red, hope is a good thing, maybe the best of things, and no good thing ever dies." -- Andy Dufresne

When patients come to the ICU, they and their family often don't know what they are in for. They might know they are sick but they might not realize just how remote the chance of recovery is. However, they hope. They hope they can overcome whatever it is that afflicts them. Some might call this false hope or even denial. They say that when patients get this sick, physicians should push for advancement of code status -- basically, try to get the family and the patient to withdraw aggressive treatment and accept that they will not overcome the illness. These people argue that treating patients this sick is futile and a waste of medical resources. They maintain that physicians are the experts in all things medical and thus are qualified to tell a patient and a family when further treatment is futile.

While families might not be medical experts, they are the experts when it comes to what the patient would want, what the patient values, and what the patient is fighting for. Maybe, the patient would be willing to go through anything in order to have that extra day at home with his family. Maybe he just wants one more chance and is willing to endure the torture. People have various motives and values and there is nothing I learned in medical school that would make me an expert on what people want. Instead, I tell the patient and the family in explicit detail what doing everything entails. If they want everything done then I do so.

I try not to think about the torture I am putting these patients through. I remember each of my failures. However, I try to focus on those few that do make it -- despite the long odds. The 70 year old with multiple medical problems that had to stay on the ventilator for over 30 days before we managed to get him off. The 40 year old whose heart stopped beating (PEA code) but who was resuscitated and went home with his family 6 days later.

If we succeed and the patient beats whatever illness is afflicting him, so much the better. If we fail, at least we gave him one last chance -- at a terrible cost, but a cost he and his family were knowledgeable of and willing to accept.

I hope my patients get better. I hope I am doing what they would want me to do.

2008-01-30T22:45:00.000-05:00

MICU

I am currently rotating through the medical intensive care unit (MICU). My day starts off at 7 am with a morning conference on a topic related to patient care in the intensive care unit. Usually we talk about ventilator management, various treatment strategies in sepsis, or the finer points about hemodynamic management. Yesterday, instead of our usual morning lecture, we had a physician interested in narrative medicine come talk to us about the importance of writing down our thoughts about what we see everyday. Near the end, we were asked to take a few minutes to write about our worst clinical experience. Here is what I wrote:

My worst clinical experience was during my first month of internship and it was in the MICU. There was a patient with lung cancer who had undergone radiation therapy and presented to the hospital coughing up blood (hemoptysis). He underwent a bronchoscopy which did not show any active bleeding. Later that same night -- around 7pm -- one of the nurses came running out of the patient's room yelling "I need a doctor!"

When we ran into the room we saw the patient sitting up on the side of his bed -- leaning on one of the side tables -- with a massive amount of blood pouring out of his mouth. I always think of hemoptysis as coughing up blood, but this was more like a fire hose pouring blood out of his mouth. There was blood all over the floor. While some of us were trying to move the patient so that his left side was down, others were throwing isolation gowns onto the people in the room to protect us from the blood that was spewing everywhere. We could see pallor move down the patient's face. The patient was dead within two to three minutes.

The patient's wife was eating dinner with him when this started. We barely had time to move her outside the room before everything was over. Watching her try to comprehend what had just happened to her loved one was heartbreaking. As I watched his wife cry inconsolably, I felt a tremendous amount of guilt. He had come to the hospital over 24 hours ago. We had done tests and yet the problem had eluded us. Finally, he was in an ICU in one of the biggest medical centers in the country with several nurses and doctors literally sitting outside his room, and we were still too slow to save him.

This is the worst thing I have ever seen and this was the only time I have ever questioned my desire to enter the field of medicine. The feeling of helplessness and the quickness with which it all happened made this a horrible experience.

I would like to think that by working hard in medical school and during training, I would have the knowledge and the ability to at least try to save a patient's life. Even if I was not successful, I could offer the patient a chance. However, all I could do was watch him die.

2007-07-14T21:13:00.000-05:00

What Makes A Good Doctor?

Before you can achieve something, you have to know what it is that you are trying to achieve. Thats pretty easy when it comes to some things. For example, a good running back runs for a lot of yards and scores a lot of touchdowns. A good cook creates food that people like to eat. A good salesman produces the most profits for his company. But what is it that a good doctor does to be considered good?

My goal is to be a good doctor but I am not sure what this entails. I was once told that patients judge doctors on the 3 A's (in order of importance): Availability, Affability, and Ability. The emphasis here is that no matter how good you are, being nice and being there are what matter most. The alternative viewpoint is that results are what matter. A good doctor is a doctor that can cure you of whatever ails you. If he or she is nice, so much the better, but this certainly doesn't come into the equation of defining a doctor's quality. Both of these measures of a doctor's quality are from the patient standpoint. If you ask doctors who they consider to be good doctors, they will envariably point to a physician with impeccable credentials, the most publications, the best diagnostic skills, or someone who generates the most profit for the hospital. In short, physicians judge other physicians not on character or medical results but on criteria that are often not even available to the public. Do you know where your doctor went for medical school, residency, or fellowship? Do you know which journals he or she has published in? In a cynical moment, one of my attendings once quipped that "You go into academic medicine if you want to be thought highly of by your fellow physicians and you go into private practice if you want to be thought highly of by your patients. " Maybe there is some truth to that.

In Doctor, Edward Rosenbaum, himself a physican, writes about his experience as a patient. He ends the book by commenting on what he thinks makes a good doctor: Ability and Integrity. In Dr. Rosenbaum's mind, those are the only two things that matter when deciding if a doctor is good. It sounds simple enough but an entire book can be, and was, written on what those two terms entail.

While I try to figure out what being a good doctor entails, I try to follow the following rules that were passed down to me from one of my attendings. Maybe this isn't the key to being a good doctor, but I hope these rules will at least keep me from being a bad doctor:

1) Be honest. At first glance this just means don't lie to others. But, it also means be honest to yourself -- know your limitations and when to ask for help. And finally, being honest means being reliable. If you say you're going to get something done, make sure it gets done.

2) Treat every patient as if they were family. This doesn't mean get emotionally tied to their case so that you can't make clear decisions. What this means is, pay as much attention to detail on each of your patients as you would if they were your family member, and advocate for each of your patients as if they were your loved ones.

3) Have fun. You can't do a good job unless you enjoy what you are doing.

Sounds pretty simple. Be honest, be considerate, and have fun. If it is really that easy why don't we have more good doctors?

2007-05-17T19:05:00.000-05:00

NO VACANCY

Imagine that you booked a hotel room for $150/night and when you arrived at your room you found out that you would be sharing it with a complete stranger. You would each have your own bed of course, and the room even comes with a nice thin yellow curtain that can be used to partition the room in half. Both of you would share the same bathroom with the bonus option of requesting a portable commode so that you could conduct your business right at the bedside. Unfortunately, that nice yellow curtain isn't thick enough to block out smells or noises.

Am I the only person who would find such a situation unacceptable? And yet, these are the exact same conditions we subject our patients to when they are admitted to the hospital.

A shared double room is the norm and patients requesting a single room are frequently charged extra. Sometimes patients get lucky and land a single room without having to pay extra but this is usually only happens when the double rooms are all booked.

What's the problem with sharing a hospital room? How about the increased risk of hospital acquired infections? Frequently, patients with communicable diseases aren't identified when they first hit the door. Only later is it discovered that the patient has C. Diff (diarrhea), MRSA (skin infections), or some other super-bug that is resistant to many antibiotics. Being in the same room, sharing a common bathroom, having hospital personnel move back and forth between you and your roommate increases the risk that these infections continue to pass throughout the hospital. This is why once patients are identified with certain infections they are moved into single rooms. However, these isolation measures are frequently only implemented once the patient has interacted with multiple hospital staff and his/her roommate. If we really cared about stomping out hospital acquired infections, we would start by requiring all patients to be in single rooms. Unfortunately, these changes probably won't occur until a patient is afflicted with a hospital acquired infection and sues the hospital because he was placed in a room with someone that was also infected.

The counter argument hospitals will make is that there just aren't enough beds to make such a change feasible. Interesting when you consider that there is enough money to continually build more research buildings and operating rooms. We have enough money to spend billions on research infrastructure but don't have the millions required to insure that the patients don't get harmed by the very hospitals to which they go for help. Of course, building more research buildings, opening more operating suites, and buying more MRI machines increases the revenue of a hospital. Ensuring each patient gets his/her own room only hurts the bottom line.

2007-05-10T21:06:00.000-05:00

Pity is a horrible feeling to have

I am currently on the solid oncology service (think lung cancer, breast cancer, colon cancer, etc... basically, anything other than leukemia and lymphoma). I recently took care of a lady that taught me how much my own preconceived notions affect my medical decision making.

When I first met Ms. M, she was clad in hospital garb -- she was barely covered in a faded, wrinkled hospital gown. A large central venous catheter, the size of a number two pencil, was attached to a vein in her neck and held in place by gauze and tape that were covered with dried blood. Her scalp was covered in some places with short, stubbly hair and was completely bald in other places. She was lying in bed staring off into space while the nurse fiddled with the catheter in her neck.

When I walked into the room and introduced myself she gave me a weak smile. She looked like she was about 60 years old. In fact, she was 40 years old. Just a few years ago, Ms. M had been diagnosed with breast cancer. Originally, the cancer was localized to just one breast. She underwent surgery and lived worry free for one year before the cancer returned. The recurrence was confined to the same breast. However, this time she underwent bilateral breast removal. She also underwent chemotherapy and radiation treatment. The worry free period this time around lasted just a few months and then the cancer returned. It had spread to her liver and bones. She was started on a very aggressive chemotherapy regimen. Her body was unable to withstand the side-effects but the tumors kept growing. Currently she is on her third different regimen of drugs. Despite all this, she has continued to live independently and is active at work and in her community.

She had been admitted to the hospital on Sunday after noticing dark blood in her stool and vomiting bright red blood. In the emergency department she had a very low blood pressure and was admitted the intensive care unit. The GI experts were consulted and she underwent an emergent endoscopy of her esophagus and stomach. This study was done to look for a source of the bleed. However, no source was found. Her blood pressure improved and her blood counts remained stable. She was transferred to the regular medicine floor after spending three days in the intensive care unit. This is when I walked in. I described her to the rest of my colleagues the next day as "An older than stated age female with past medical history significant for widely metastatic breast cancer who presented with a presumed upper gastrointestinal bleed and hypotension (low blood pressure)." Based on just my few first words the rest of my team had already formed a picture of this person. They knew, despite anything more I would say, where I was going with this. Our team decided that she had a very poor prognosis. We declined further workup of her bleeding. We focused on making her comfortable and getting her home as soon as possible.

She was discharged from the hospital today. I was about to leave the hospital when I remembered that I had forgotten to give her one last piece of information. I walked into her room and halted. There were two people in the room sitting comfortably in chairs chatting about where they planned to go tonight. I thought I must have walked into the wrong patient's room. Both of these ladies were very well dressed and appeared to be in their 30s. They were both beautiful. Just as I was about to apologize and excuse myself out of the room, I realized that the lady on the left looked very familiar. It was Ms. M. She was dressed in her normal clothes. She was wearing makeup. She was wearing a wig that made her appear to have long brown hair. The faded, wrinkled hospital gown lay on the bed. The lady that sat before me was a completely different woman. I stammered out what I had come to say. We made small talk and then I left. As I walked away from the room I was gripped with doubt. This lady looked great. Maybe we should have kept her in the hospital and figured out why she was bleeding. We should have been more active in our search. She had told me she was active at home and at work but I hadn't really believed it until I saw her sitting there with her friend.

Did the fact that she could cover her head with a wig and make herself look young mean she had any better of a prognosis? Probably not. Did we do anything wrong? Hopefully not. But, would my workup have been different if I had seen the younger looking, well groomed, and seemingly healthier Ms. M the first day? Almost certainly. Ms. M will follow up with her primary oncologist next week. He is one of the better doctors at our hospital and knows her well. I hope I am not just passing the buck.

I can't help but feel guilty about this case even though I don't think we did anything wrong. Ms. M was presented with the options and she agreed with the team that most of the workup could be deferred or done as an outpatient. Why then do I feel that I short-shrifted her? I think I feel guilty because of my own initial feelings of pity. I presumed that his frail looking, sickly woman had little to look forward to. I couldn't have been further from the truth.

2007-04-22T13:57:00.000-05:00

Patient Empowerment: A Case Study

Nirali Naik is a young girl with leukemia (ALL). ALL responds well to bone-marrow transplant but because she is Indian it was unlikely that she would find a matching donor in the national bone-marrow registry. Her parents became proactive and coordinated bone marrow screenings for Indian Americans across the US. They also set up a website that updated everyone on their daughter's condition. Take a look at their website and spend some time reading the section Updates about Nirali to get a better idea about what this family has gone through.

Donald Berwick, the president and CEO of the Institute for Healthcare Improvement and once called the third most important person in American healthcare, gave a speech in 2002 titled "Plenty." He emphasized the importance of focusing on the abundance of resources that patients and physicians have at their disposal, namely the patients and their families!

"Patients and families bring to us their expertise, their commitment to themselves, their love of each other, their houses, their gardens, their hobbies, and most of all their innate, natural capacities to heal. Nature has spent 3.8 billion year of R&D developing biological healing capacity, and it walks into our doors -- free, for nothing -- wanting to help get done what we are trying to get done -- survival, healing. The selfish gene wants to work for us."

I believe that the Naik family is what Dr. Berwick has in mind. If we can get patients and families to be as involved and educated about their health as this family has been, I believe we gain a tremendous ally in our fight to better healthcare. If you would like to read more by Dr. Donald Berwick, pick up his book Escape Fire: Designs for the Future of Health Care.

2007-04-20T13:50:00.000-05:00

Are You Racist?

Project Implicit: http://implicit.harvard.edu

What biases do you have?

2007-04-16T22:34:00.000-05:00

The July Phenomenon

Hippocrates implored physicians to "First do no harm," and yet in the process of learning how to practice medicine, I wonder how much harm I've already done.

Medical education is one of only a few instances in health care (the others being medical research and control of communicable diseases) when the interests of the individual are sometimes superseded by the interests of society. However, unlike with medical research where the risks and benefits are plainly laid out for patients, medical education leaves no room for full disclosure. The "See one, Do one, Teach one" mentality is common amongst physicians but I wonder how many patients know that such a system (however unofficial) exists.

The first issue is whether or not there is risk associated with having relative novices "practice" medicine on patients. New housestaff start their training in July and the bump in complications during July is euphemistically referred to as the July Phenomenon. Hypothetically, new trainees are more closely supervised to ensure that there is no harm to the patient. However, in my personal experience, this oversight is oftentimes shoddy and inadequate. A recent study examined how comfortable medicine trainees were with their own competence in performing various procedures. The results showed widespread discomfort with performing most of these procedures. More simply, ask yourself how good you were when you first did something that required even an iota of physical skill -- hitting a baseball, catching a Frisbee, painting a picture -- and then think about how your ability improved as you gained experience. Common sense tells us that the more experience we gain, the better we do.

If there is even a slight chance that patients are at higher risk by having new trainees perform procedures on them, shouldn't they have the right to know? However, most physicians argue that patients that come to a teaching hospital are aware that they will have trainees work on them. Unfortunately, this is far from the truth. Up to 60% of patients presenting to teaching hospitals were unaware that they could have procedures done on them by physicians that had never done the procedure before. Clearly, there is chance of increased risk with novices performing invasive procedures and this risk is not clearly explained to patients. Just as we do with experimental drugs and new procedures, I believe INFORMED consent has to be obtained whenever patients are exposed to physicians in training.

Wouldn't this proposal hurt our great medical education system? Who would want to be the guinea pig? I would like to believe that full disclosure would not hurt medical education. Just as we continue to lead the world in the development of new drugs and innovative procedures (that were all once tested on volunteers), I believe we will continue to have a great medical education system. How can I know this for sure? Consider the following two facts:
1) The same study which showed that up to 60% of patients were unaware that they would have trainees practice on them also found that about half of those very same patients would still undergo the procedure even if it was the first time the physician was performing the procedure.
2) Teaching hospitals as a whole usually have lower mortality and morbidity rates compared to non-teaching hospitals. This is usually attributable to the fact that these hospitals have higher patient volumes. In contrast to the individual rookie physician who might not be great at performing any given procedure, the combined expertise of a large teaching hospital provides a great safety net that results in very good patient outcomes. Also, as physicians in training start doing procedures they become competent very quickly. The key is to make sure that they don't hurt anyone in the time it takes them to become competent.

Going through medical school and currently being a resident makes me a pretty informed consumer on where to get my health care. As a patient, I have never had any qualms about going to teaching hospitals. However, I make this choice after knowing all the facts. I just wish my patients knew all the facts.

2007-04-15T09:18:00.000-05:00

Economic Incentives and Weight Loss

We have several pills to control blood pressure, decrease cholesterol levels, and fight type II diabetes, but what about a pill that makes people take responsibility for their own health?

Two thirds of Americans are overweight and close to one third are obese ( Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002) . "For the first time in human history, the numbers of overweight and underweight individuals are about the same, at 2.1 billion each." To emphasize how uncontrollable the obesity epidemic has gotten, consider that there are starving people in Sub-Saharan Africa while in the US we have competitions (The Biggest Loser) about weight loss!

High blood pressure, high cholesterol levels, diabetes, several types of cancer, joint disorders, and complications after surgery have all been shown to be affected by weight. Simply put, the more you weigh, the more complicated your medical course, and subsequently the more your medical care costs to yourself and to society (Medicaid spending for obesity related health problems has soared over the last 20 years)! Obesity related health care costs have risen dramatically over the last 20-30 years and medicine's only response has been to encourage better eating and more exercise -- something that Dr. PD White emphasized in the 1950s! Obviously our emphasis on better lifestyle is falling on deaf ears! Not surprisingly, when we are competing against the marketing budgets of Coke and Pepsi, the explosion of all you can eat buffets, and the growing emphasis on fast food. Complicating this, healthy food (fresh fruit/vegetables) is increasingly more expensive. People eat unhealthy because the food tastes good and its cheap!

What happens if we make fast food more expensive and healthy food cheaper? You can offer individuals a break in insurance premium and tax benefits for losing weight or joining a gym (and demonstrating active membership). Small studies have shown that financial incentives to promote weight loss work in the short term (Effects of outcome-driven insurance reimbursement on short-term weight loss. International Journal of Obesity. 2003). My current insurance plan will pay half of my gym membership dues.

Another option would be to focus your efforts on the companies that are facilitating unhealthy eating habits. We can make fast food more expensive by taxing it and make healthy food cheaper by providing tax breaks to companies that supply healthy food. Studies have shown that as taxes for other unhealthy products (such as tobacco and alcohol) have increased, use of these products has decreased.

Of course, we would have to have a process to define unhealthy/healthy food. I think we can all agree that a Big Mac, large order of fries, and a large coke isn't the breakfast of champions.

Some of you will read this article and think that no matter how expensive we make unhealthy food, people will still eat it. I've seen Bradley, a friend of mine from high school, scarf down several Wendy burgers and milkshakes in one sitting and I doubt increasing the price will affect his desire to eat this food. Somehow he manages to retain his girlish figure despite his eating habits -- a testament to the importance of genes and exercise, but that is a topic for another day. My response: So what. Let them eat unhealthy. Let people be overweight. But at least this way they will be contributing to their own health-care costs. The taxes gotten from this program should go to fund local health-care infrastructure. Just as we tax tobacco we should tax unhealthy food and use this money to improve our health-care system.

Either this program works and the prevalence of obesity declines and health care costs decrease or this program doesn't work, obesity rates continue to increase, but we have a way to fund the increasing demand in health care. Either that or we get to work on a pill that makes people care about their health.

Fast Food Calorie Counter

2007-04-12T20:28:00.000-05:00

PERFORMANCE

If you have some free time, read Autl Gawande's new book Better. Gawande's discussion of how to become a better doctor hits very close to home for me as both a patient and a physician.

Contrary to what most physicians would like to think, just graduating from medical school or even going through a well reputed residency/fellowship does not make a good doctor. In fact, medical outcomes for different physicians and hospitals vary widely (The Bell Curve). In one part of his book, Gawande discusses allowing patients to know how doctors perform on various performance criteria. For example, a few states keep public records on the complication rates of all cardiac surgeons. Also, the Cystic Fibrosis Foundation keeps very detailed records detailing how each cystic fibrosis center in the nation performs against the national average on several important criteria.

Many physicians fear that the creation of these criteria (that will be available for everyone to see) will create an incentive to direct care towards the criteria and not towards each individual patient. Physicians might order tests just to check off a box and get a better rating, instead of thinking about whether or not the patient really needs the test/intervention. In addition, physicians argue that no set of measures can truly gauge the competency of a physician. Diagnostic acumen, integrity, and compassion are all important traits in a physician that are hard (if not impossible) to measure. In summary, the main argument against performance measures is that they are incomplete and they force physicians to disregard individual variation.

However, this does not mean that this data is not useful. I'll be the first to acknowledge that medicine is complex enough that no single group of performance measure will truly capture a physician's full ability, or lack thereof. I know plenty of physicians/medical students that might do great on tests, know all the answers on rounds, and be able to spout the latest data from the most recent research, but that I wouldn't trust to treat me or my family. You want your doctor to be compassionate and have integrity. But you also want your doctor to be able to cure you of whatever is ailing you. None of these factors is easy to measure. So, how do we figure out if our doctor is good.

I believe that information about adherence to performance measures and mortality/morbidity data for each physician should be recorded and made public. The combination of both of these pieces of information will allow patients to make a more informed decision. For example, if a physician does not adhere to well established criteria and has below-average morbidity/mortality rates, I think his prospective patients have a right to know this information. Hopefully, as physicians see that they lag in both categories, they will be encouraged to make changes to improve their patient outcomes. This might mean adhering to established criteria or it might mean innovating and finding new ways to improve patient outcome. This database will allow identification of physicians that do not adhere to the performance measures but have great outcomes. The establishment of a database that combines both of these factors will allow both patients and physicians to see what these innovative physicians are doing and hopefully allow for innovation in patient care that is evidence based.

This data will make patients more informed consumers, but in the end patients will still have to judge based on individual experience whether or not the doctor they pick is the right doctor for them. You might go to the physician with the best record of adhering to performance measures and the best outcomes and find that he is a jerk. Or you may go to a physician with a great record and find that he only treats the rich and famous (his patients come to him healthy) and he isn't doing much for them. Currently, patients pick doctors based on word of mouth (either through what their family/friends recommend or what another doctor recommends/refers). Having some solid information to base important health decisions on can make patients more informed consumers and encourage better patient care.