Thursday, September 24, 2020

Doctors need to care: It's about the patients, not about you


 Recently, a friend of a friend had an accident and fell in her driveway. After two days of pain that did not improve, she went to an urgent care center where an x-ray was taken and the PA told her that there was no rib fracture and her lung had not collapsed, so she went home. The next day the urgent care center called back and said “whoops, there is a rib fracture and you do have a collapsed lung”. They said they’d call her primary care doctor, but didn’t. The patient tried to, but the doctor was on vacation. The covering physician refused to see her. So our mutual friend, who is a physician and surgeon who lives 1000 miles away, called someone who lived in the patient’s town to take her to the emergency room. There, they re-x-rayed her, and admitted her to the hospital, telling her that they would need to insert a small tube to remove the air (called a pneumothorax) from around her lung. The doctors said she refused the procedure, although she says she just asked some questions about it. She was admitted for “observation”, and given oxygen. In the morning, since the x-ray was no better, they said that they would have to keep her in the hospital, but this later was reversed on a visit from the resident on the hospitalist service, who said she could go home.

 Our mutual friend called the resident, asked about it, was told that it was OK to discharge her (quoting the “resident’s best friend”, the medical information website UpToDate®) and would not put the friend in touch with the attending physician. However, the patient was terrified about going home, especially given her accident, that she lived alone, that she had had her bad experience with the urgent care center, and that her physician was out of town. I suggested that our mutual friend might try to contact a hospital administrator to see if the attending physician could be reached. Then I got a message that there was a new hospitalist over the weekend, who happened to be a family physician, and who tried a novel approach: she talked to the patient, examined her, and reviewed the chest x-rays. After this, she decided to call a pulmonary specialist, and it was decided to insert a chest tube. The patient, with the proper treatment, improved and should get better.

 So probably the story will have a happy ending, at least from the point of view of ultimately getting the right treatment. The woman who was the patient may recover physically, but is unlikely to recover a lot of faith in what is amusingly called our health care “system”. The number of things done wrong were many, and most could be blamed on the individuals; the PA in urgent care who mistakenly thought that they could accurately read the chest x-ray, the provider in the emergency department who was apparently in too much of a rush to answer her questions and decided the fact that she had them meant she was refusing the recommended treatment, the hospitalist service who changed their mind about her need for hospitalization without explanation, the resident who would not contact the attending physician, and the attending physician who apparently did not want to be contacted.

 But to blame just the individuals would be incorrect, although we can be very enthusiastic in lauding the weekend hospitalist who decided to actually care for the patient. The system is critical here. I do not know that hospital, but I imagine the doctors in both the emergency department and on the hospital floors are stressed an overworked, and that the way they responded to the patient in question, while unjustifiable, was probably caused in part by that overwork and stress. The resident may have been the “point person” in contact with the patient, but the service attending was ultimately the one making the decision. Poor role modeling by attending physicians and senior residents is common and leads to poor behaviors by residents, who are often more concerned with their own workload or pleasing their bosses than providing proper patient care. In such busy situations, patients are often assessed quickly, and judgements are made not just regarding their medical problem, but their personality. Are they going to be a “good patient” – meaning that they will quickly accede to doing what I am recommending -- or are they going to cause me “trouble” and cost me time? That trouble can be real if the patient is aggressive, intoxicated with alcohol or other substances, or has a serious mental health diagnosis, but it is sadly true that the label “troublesome” patient can even be applied to someone who asks perfectly appropriate and reasonable questions about the treatment being proposed for them.

 Racism provides us with a bit of a metaphor, in the sense that there is both an individual and a structural (or institutional) component. Yes, behavior by individuals can be inappropriate and wrong and blameworthy. But if we leave it at that, if we do not understand the overall structure that encourages or facilitates such individual behavior, we will never solve the problem. We will never decrease or end racist behavior, and we will never ensure that patients get treated with the respect and concern that they should. Racism affects the medical system and medical education as it does the rest of society, but disrespect and self-centeredness can inhibit appropriate medical care even when race is not involved. Indeed, in this case the patient was a 70-ish middle-class white woman. One can imagine with what frequency, and to what degree, people are treated with disrespect – and poor medical care – when they are members of minority groups, poor, homeless, have a psychiatric diagnosis, are not clean and nice-smelling, are not coherent, are under the influence of a substance, etc. Of course, if one is a health care worker, one need not imagine it; one sees it all the time.

 As a family doctor, I would like to take pride in the fact that the “hero” of our story also was one. In fact, I will. I actually believe that the training of family physicians, and the emphasis on caring for the patient rather than a particular problem, makes a difference, and enhances the caring characteristics of the individuals who choose to enter this specialty. That is, I think it is more than a coincidence. However, of course there are wonderful caring physicians, including resident physicians, in every other specialty, as well as family physicians who are jerks. I just think that it is a smaller percent.

 Should there be any jerks in medicine? I have heard it argued that in some specialties, it is not necessary to have good “people skills”. In pathology, or diagnostic radiology, or even anesthesiology, where the doctor spends little or no time with living patients. Or in surgical and other procedural specialties, where technical skill, not “bedside manner”, is what matters. Sometimes I have acknowledged that this made some sense. Until I thought about the colleagues I have had in every specialty. And in every case the good ones cared about the patients they were involved with, whether or not they met them face-to-face.

 The pathologist or radiologist knows it is also their patient, and the use of their skills in the performance of their jobs may make the difference in a person’s life, or death. They care. Caring may not be the same as “people skills”; we recognize that some people have greater difficulty connecting directly with others, and are certainly not trying to create a profession full of hucksters and snake-oil salesman with false charm. But we do want one whose practitioners can convey concern, and caring, and at the minimum not disparage the people who are in their care.

 So, yes, I think that everyone admitted to medical school should care about people. And, yes, I think that we need to ensure that our medical education does not beat or role-model it out of them. Our residents need to have schedules and lives that are reasonable enough that, when they are tired or frustrated, they don’t act out. Our attending physicians need to be available.

 Even when you are tired or overworked, it is not ok to be cruel or insensitive any more than to be racist or sexist. After all, there is a reason that this profession exists, and it is not to provide a good life for the practitioners. It is to try to maximize the health of the people for whom it cares.

Tuesday, September 15, 2020

"If the only tool you have is a hammer..."

 “If the only tool you have is a hammer, everything looks like a nail”.

 This old adage has been applied in many contexts, and sometimes appropriately to the work of medical specialists, particularly those who do procedures. It is something that family physicians and other primary care doctors are only too well aware of; before referring a patient to a specialist equipped with their hammer, we like to do our best to make sure that this is the right tool for the job. Perhaps, metaphorically, the family physician has the full range of tools on their belt and can thus address most medical problems, but sometimes the complexity of the treatment that a patient needs requires someone with great expertise. Pushing the metaphor, a general contractor might think that a particular job needs a skilled electrician.

Sometimes, really a lot of the time, subspecialists are consulted for their opinion of a problem, because it is an area in which they have in-depth knowledge. This is not a bad thing at all, as long as that opinion is guided by the evidence that exists and not by the doctor having limited their knowledge to the extent that they know only one approach, or, worse yet, are guided by the potential to make money doing a procedure. This happens, but, thankfully, less often than it could. Most commonly, the issue is not lack of knowledge on the part of the specialist, or even greed, but rather a sense of what others expect of them.

If you present to a primary care doctor with chest pain that sounds like acid reflux, they’ll probably prescribe treatment for acid reflux, with caution about changes in the character or frequency of the pain. If the pain sounds a little more suspicious for cardiac angina, they might refer you to a cardiologist. After examination, history and physical, the cardiologist might think it is probably acid reflux. But – and it is a big but – because they are a cardiologist there is a good chance that they will maybe do more tests, expensive and possibly invasive, because, since they are a cardiologist, missing a potential cardiac diagnosis would look worse. Plus, even if the cardiologist is not greedy (or is even on salary, not paid per procedure) the organization they work for might want them to run profitable tests.

For the society, this means a lot of extra tests are done, and this is costly. For the individual, especially if they are uninsured or poorly insured with a big deductible or co-payment, it can be particularly costly. Plus, for the individual, it can be risky – few procedures have no risk of harm, and the more extensive and invasive the greater the risk. That said, they can also be beneficial or even life-saving. The key is to do them when they are necessary, or the evidence suggests that the probability of benefit outweighs the risk of harm, and not otherwise. Of course, we ourselves, patients (or, to use the English word, people) often demand an “answer”, even if the answer is not going to be clear and/or the methods for obtaining it not without risk. When I tell people that the results of their tests to rule out potentially dangerous causes of their symptoms are normal (I try to not use “negative”, which sounds, unsurprisingly, negative!) they often respond “But what is it?” I have to tell them that I still don’t know, but I have discovered it is not something that is really bad. That is always a good thing. Finding out that the cause of your symptoms is not cancer, for example, doesn’t tell you what it is, but it is  lot better than finding out that it is cancer!

Of course, this whole incentive to intervene, to do more sophisticated, high-tech, complex, invasive, and expensive tests or treatments, applies only to that segment of the population that is well-insured or rich. It is an incredible source of inequity, because a different set of decision rules is applied to different groups of people depending on their ability to pay rather than the medical need (or lack thereof). Yes, people with good coverage may get too many tests, which not only cost a lot and have some risk of harm in themselves, but also can snowball into needing to repeat tests or do more complicated ones if there is a suggestion of abnormality in the first set. [Think of the math in terms of something as “simple” as panels of laboratory tests. “Normal” is usually based on 2 standard deviations from the mean value in that lab, 95%, so 5% of normal people might have an “abnormal” test result. But if 20 tests are done – and their results are independent of each other – the probability that someone’s results are “normal” on all 20 might be .95^20 or about 35%!] This can result in harm to people with money.

However, it is still more common for people without money or good insurance to suffer harms because they do not get the testing and treatment needed. And, unsurprisingly in the US, racism enters into the mix; Black Americans are less likely to get recommended diagnostic and treatment interventions for heart disease than White, even when they are insured!

What can be done? Changing medical education to teach that interventions should be done based on the overall evidence, not evidence selected to lead in a particular direction, could help. This has actually improved; when I was in medical school most of the surgical literature, for example, was case series (“We did this procedure on X people, and this many got better and that many died or got worse”) without control groups or controlling for how sick people were. (A famous study in my medical youth compared surgical intervention for coronary artery disease with medical treatment. Surgical was better. Of course, all the people with other diseases that made them at higher risk for surgery were allocated to the medical treatment group!)

Another very big thing would be to make sure EVERYONE is adequately insured. Not more people, but everyone. And, best, with the same insurance, so there is no gaming the system to get the folks whose insurance pays the most. If everyone has the same insurance – most simply, improved and expanded Medicare for All, there is no financial reason to do, or not do, tests or treatments on anyone (this would not,of course, cure racism).

Also, more primary care doctors would be great. As research presented by Etz and Stange at the recent Society of Teachers of Family Medicine (STFM) conference, and published in the Annals of Family Medicine has shown, currently primary care sees 50% of all physician visits (500,000,000) with only 30% of the workforce and <7% of the dollars (and, for the academic researchers, 0.2% of NIH funding).  More primary care physicians, which would almost certainly result from (and probably require) a lot larger portion of the money spent on health care to be directed to primary care, would almost certainly lead to more equitable and higher quality care for everyone.

A highly-placed non-medical health care executive once asked me (a family doctor) why he would go to me with a prostate problem instead of a well-known urologist. Skipping over “how do you know it’s a prostate problem?” I said “I guess it depends upon whether you want surgery or not.” Oversimplistic, perhaps, since urologist might provide other options, but not entirely unrealistic. The urologist’s job may be, in part, to care for prostate problems, but their training is to operate. 

By the way, the executive had no follow up questions.

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