Recently I was interviewed on the local NPR radio station (KUOW) by producer Katy Sewall. In the first of a three part interview Katy started out by asking me to describe a "good death". Candidly, I had to struggle a bit with the answer, because "good" can mean different things to different people. Basically it seems to me that if we, as medical providers, can adhere to the patient's wishes then they can pass from this world in a way that respects and dignifies them as a person. If interested, here is the podcast of the interview (it begins about 12 minutes into this Podcast and lasts for about 17 minutes: http://www.kuow.org/post/week-olympia-what-makes-good-death-and-onlies
A second portion of the podcast interview which is more focused on medical interventions is available: http://kuow.org/post/return-787-ancient-maya-and-end-life.
Tuesday, May 14, 2013
Thursday, May 2, 2013
Videos of CPR Aid Informed Consent
When my Dad was 94 years old and in a nursing home in western Pennsylvania, I got a call from my sister, "Jim, Dad's losing weight and seems to be withdrawing. I'm worried about him. The doctor's doing some tests today."
Well, one of the many tests turned out to be a chest and abdominal CT scan. His heart was enlarged (we knew that from his history) and everything else was normal except for a 1cm spot on his left kidney. Whether this was benign or malignant was clinically irrelevant but my sister was worried. "Shouldn't it be biopsied or removed?"
I replied, "I don't recommend that. It couldn't be causing his lack of appetite or general dwindles. Even if it is a small cancer, it's very unlikely to ever cause him a problem. A medical intervention may well harm him."
I had to pull some strings to set the direction toward comfort care, which is what he always said he wanted. But what if I hadn't intervened? Often, we almost mindlessly opt for more intervention, a diagnosis, a new drug, or a "life saving" treatment - even in a 94 year old trying to approach the end of his life in a dignified way.
There are a variety of attempts in our country to figure out the most effective way to have "the conversation" with patients and families about end of life values, options, and choices. It's pretty clear that pamphlets, words, and discussions aren't enough by themselves. Harvard physician Angelo Volandes has found that videos of things like dementia care and CPR may profoundly alter the choices that patients make.
In a calm manner Volandes' physician spouse, Aretha Delight Davis, presents factual data during the videos. This visual learning appears to be much more powerful than verbal descriptions and may affect our choices on intervention.
It's nearly universally felt among physicians, that we're overusing the "technologic imperative" at the end of life - often depriving the patient the opportunity to die at home surrounded by loved ones and receiving support from hospice and palliative care. As one patient told me, "If I wake up in the next life attached to tubes, I'll know where I've gone."
Well, one of the many tests turned out to be a chest and abdominal CT scan. His heart was enlarged (we knew that from his history) and everything else was normal except for a 1cm spot on his left kidney. Whether this was benign or malignant was clinically irrelevant but my sister was worried. "Shouldn't it be biopsied or removed?"
I replied, "I don't recommend that. It couldn't be causing his lack of appetite or general dwindles. Even if it is a small cancer, it's very unlikely to ever cause him a problem. A medical intervention may well harm him."
I had to pull some strings to set the direction toward comfort care, which is what he always said he wanted. But what if I hadn't intervened? Often, we almost mindlessly opt for more intervention, a diagnosis, a new drug, or a "life saving" treatment - even in a 94 year old trying to approach the end of his life in a dignified way.
There are a variety of attempts in our country to figure out the most effective way to have "the conversation" with patients and families about end of life values, options, and choices. It's pretty clear that pamphlets, words, and discussions aren't enough by themselves. Harvard physician Angelo Volandes has found that videos of things like dementia care and CPR may profoundly alter the choices that patients make.
In a calm manner Volandes' physician spouse, Aretha Delight Davis, presents factual data during the videos. This visual learning appears to be much more powerful than verbal descriptions and may affect our choices on intervention.
It's nearly universally felt among physicians, that we're overusing the "technologic imperative" at the end of life - often depriving the patient the opportunity to die at home surrounded by loved ones and receiving support from hospice and palliative care. As one patient told me, "If I wake up in the next life attached to tubes, I'll know where I've gone."
Saturday, April 27, 2013
The Physical Exam - a Lost Art?
Bobby was admitted to the hospital once again with overwhelming fatigue and shortness of breath. Yet this 37 year old farmer looked the picture of health. He grew up on a farm rising before dawn, milking cows and working long days in the fields with hay or corn. He was never seriously ill as a child and was a good football halfback in high school.
But this was his third admission for evaluation. He had been through heart and lung tests and even a psychiatric examination but everything was coming up normal. As is usual at a University Hospital Bobby's first "doctor" on that admission was Mike, a third year medical student who was being examined himself on his ability to evaluate a patient.
Mike spent about a hour going though Bobby's extensive chart: normal blood count, electrolytes, liver function, kidney function, calcium, and thyroid tests. The urinalysis was normal, as was the chest X-Ray and EKG. He had baffled the medical residents, research fellows, and faculty - so what in the world could he contribute?
Bobby told his story once again, "I feel OK when not doing much, but when I try to climb a ladder or haul some hay I just feel all in. There's no pain, but I just feel like keeling over." His treadmill test showed that he was limited, but no sign of coronary artery disease.
Mike noted this history at the beginning of his new evaluation, the "chief complaint."
"I'm going to ask you a bunch of questions you've probably been asked before, do you mind?", asked Mike.
"Not if you can fix me up, I don't want to die from this."
"OK, let's start way back. Tell me your story about growing up, I need to find all I can about you."
So Mike became a listener and Bobby began to tell stories from childhood, some of which we're pretty entertaining like tipping over outhouses at Halloween, once with a farmer inside!
"In fact, said Bobby, that guy was as mad as a hornet. We were running away, and I climbed over a fence, when he cut loose with his shotgun. Maybe he was just trying to scare us, but I took some buckshot in my rear."
For some reason, this intrigued Mike. He hadn't found anything in the prior records about trauma. "So what happened, did you need surgery?"
"No, but there were a bunch of skin holes and we only got out one or two pellets. It looked like I had chickenpox on my ass!"
Mike tucked this bit of information away and finished up with his hour long interview and taking of notes on family history, social history, occupational history, etc. He knew this was going to take hours to write up for his examiner. But as he was thinking, he couldn't get his mind away from the puzzle of the shortness of breath: it didn't seem to be heart disease, lung disease, or other organ failure, so what was it?
With an educated whim, Mike asked Bobby if anyone had ever listened to his bottom with a stethoscope. Bobby whooped, "Now wouldn't that be something. No nobody's touched my butt outside of my wife, that's for sure."
"Now Bobby this is going to seem more than a little crazy, but I'd like to check you there to see if the buckshot caused an unusual injury."
"Hey, Doc I'm desperate. If you think putting your stethoscope on my ass is the answer, then what the heck" said Bobby laughing.
With Bobby prone and rear exposed, Mike could see the multiple buckshot scars on the right buttock and thigh. He couldn't see any pulsations, but when he first placed his hand over the area he could feel a gushing sensation, which in medical terminology is called a "thrill' - perhaps a misnomer for trill. But it was a definite harmonic vibration with each heart beat. The stethoscope was next applied and revealed a very loud (grade 6/6) "murmur" - another strange medical term from the older lexicon.
Mike wasn't sure he had found the actual problem or, if so, anything could be done to fix it. The next day, on rounds with students, residents, and faculty zipping though the rounds with rapid file questions and orders they came to Bobby's bed. Bobby was beaming and couldn't contain himself, "Hey doctors, my bright young doctor here has found a murmur on my ass, how about that?"
Mike gulped, this wasn't how he had planned to present the problem. He did manage to give the gunshot history and detail the physical findings. At first there was skepticism by the junior staff that the findings were significant. But the senior cardiologist was savvy and recognized the brilliance of Mike's discovery. He said, "It's pretty clear to me, that this patient has high output heart failure. I would guess that he must be loosing 50% of his cardiac output to a shunt between a large pelvic artery and vein. He can function OK at rest but goes into high output heart failure with exercise because of the shunt."
Comment: That's how it turned out. Bobby's shunt was viewed with a dye contrast study and the vascular surgeons consulted. A large artery and vein had been joined together by the penetrating trauma of the buckshot. It was relatively straight forward surgery to close the shunt thus returning the blood flow to a normal pattern.
I wish I could say I was Mike in the story, but I was one of the many who missed the diagnosis. But I did learn that many medical problems can be uncovered by a good history followed by a detailed physical exam. As one professor said, "Listen to the patient with your eyes, ears, hands, and stethoscope."
In many ways physicians have mistakenly moved away from the comprehensive physical exam in favor of the high tech evaluations. Abraham Verghese who is a Professor for the Theory and Practice of Medicine at Stanford University Medical School has reminded us in a TED video talk about the importance of touch, listening and the laying on of hands.
But this was his third admission for evaluation. He had been through heart and lung tests and even a psychiatric examination but everything was coming up normal. As is usual at a University Hospital Bobby's first "doctor" on that admission was Mike, a third year medical student who was being examined himself on his ability to evaluate a patient.
Mike spent about a hour going though Bobby's extensive chart: normal blood count, electrolytes, liver function, kidney function, calcium, and thyroid tests. The urinalysis was normal, as was the chest X-Ray and EKG. He had baffled the medical residents, research fellows, and faculty - so what in the world could he contribute?
Bobby told his story once again, "I feel OK when not doing much, but when I try to climb a ladder or haul some hay I just feel all in. There's no pain, but I just feel like keeling over." His treadmill test showed that he was limited, but no sign of coronary artery disease.
Mike noted this history at the beginning of his new evaluation, the "chief complaint."
"I'm going to ask you a bunch of questions you've probably been asked before, do you mind?", asked Mike.
"Not if you can fix me up, I don't want to die from this."
"OK, let's start way back. Tell me your story about growing up, I need to find all I can about you."
So Mike became a listener and Bobby began to tell stories from childhood, some of which we're pretty entertaining like tipping over outhouses at Halloween, once with a farmer inside!
"In fact, said Bobby, that guy was as mad as a hornet. We were running away, and I climbed over a fence, when he cut loose with his shotgun. Maybe he was just trying to scare us, but I took some buckshot in my rear."
For some reason, this intrigued Mike. He hadn't found anything in the prior records about trauma. "So what happened, did you need surgery?"
"No, but there were a bunch of skin holes and we only got out one or two pellets. It looked like I had chickenpox on my ass!"
Mike tucked this bit of information away and finished up with his hour long interview and taking of notes on family history, social history, occupational history, etc. He knew this was going to take hours to write up for his examiner. But as he was thinking, he couldn't get his mind away from the puzzle of the shortness of breath: it didn't seem to be heart disease, lung disease, or other organ failure, so what was it?
With an educated whim, Mike asked Bobby if anyone had ever listened to his bottom with a stethoscope. Bobby whooped, "Now wouldn't that be something. No nobody's touched my butt outside of my wife, that's for sure."
"Now Bobby this is going to seem more than a little crazy, but I'd like to check you there to see if the buckshot caused an unusual injury."
"Hey, Doc I'm desperate. If you think putting your stethoscope on my ass is the answer, then what the heck" said Bobby laughing.
With Bobby prone and rear exposed, Mike could see the multiple buckshot scars on the right buttock and thigh. He couldn't see any pulsations, but when he first placed his hand over the area he could feel a gushing sensation, which in medical terminology is called a "thrill' - perhaps a misnomer for trill. But it was a definite harmonic vibration with each heart beat. The stethoscope was next applied and revealed a very loud (grade 6/6) "murmur" - another strange medical term from the older lexicon.
Mike wasn't sure he had found the actual problem or, if so, anything could be done to fix it. The next day, on rounds with students, residents, and faculty zipping though the rounds with rapid file questions and orders they came to Bobby's bed. Bobby was beaming and couldn't contain himself, "Hey doctors, my bright young doctor here has found a murmur on my ass, how about that?"
Mike gulped, this wasn't how he had planned to present the problem. He did manage to give the gunshot history and detail the physical findings. At first there was skepticism by the junior staff that the findings were significant. But the senior cardiologist was savvy and recognized the brilliance of Mike's discovery. He said, "It's pretty clear to me, that this patient has high output heart failure. I would guess that he must be loosing 50% of his cardiac output to a shunt between a large pelvic artery and vein. He can function OK at rest but goes into high output heart failure with exercise because of the shunt."
Comment: That's how it turned out. Bobby's shunt was viewed with a dye contrast study and the vascular surgeons consulted. A large artery and vein had been joined together by the penetrating trauma of the buckshot. It was relatively straight forward surgery to close the shunt thus returning the blood flow to a normal pattern.
I wish I could say I was Mike in the story, but I was one of the many who missed the diagnosis. But I did learn that many medical problems can be uncovered by a good history followed by a detailed physical exam. As one professor said, "Listen to the patient with your eyes, ears, hands, and stethoscope."
In many ways physicians have mistakenly moved away from the comprehensive physical exam in favor of the high tech evaluations. Abraham Verghese who is a Professor for the Theory and Practice of Medicine at Stanford University Medical School has reminded us in a TED video talk about the importance of touch, listening and the laying on of hands.
Monday, April 8, 2013
Smart Cards for Your Health Care
Pierre arrives at the construction site, has his morning coffee and croissant, then ascends the scaffold to begin his work. He felt a little woozy this morning but ignored it. Becoming more dizzy, he loses his balance and falls two stories fracturing his femur and pelvis. On arrival the paramedics find his health smart card in his wallet, scan it, and instantly have his medical records including medications, allergies and importantly prior EKG's. He's found to have a new rapid irregular heart rate and given appropriate medical treatment on the way to the ER. Pierre is lucky he lives in France where smart card technology is widely applied.
Billy has severe COPD and is on multiple medications. Going out to pick up the morning paper, he trips, falls, becomes confused and can't respond logically to questions from a bystander. 911 is called and arrives. No family members are present. No medical information is available. He's transported to the hospital where it takes 3 hours to track down a partial medical history and an advance directive. There is a delay in recognizing internal bleeding until it's discovered that warfarin is one of his medications. Billy is unfortunate he lives in a state not using smart card technology.
The smart card has been around for a few decades and is in wide use in Germany, France, Taiwan and several other countries. Biometrics and other security measures have been developed to comply with patient privacy regulations. The VA hospitals are using a smart card system successfully. Other health smart card companies are competing for this potentially large market.
There are state wide and even nation wide efforts to have registries for advance directives and POLST forms in order to make them available on an emergent basis. But we are a mobile society. Individual state registries can become redundant, expensive, and hard to maintain. Oregon has the most advanced state registry for POLST forms but that is just one state. Smart cards will allow each one of us to carry around our own health care information in our wallet or purse. Privacy can be protected with use of a thumbprint. Secure readers can be portable.
The lack of wide use of smart cards in the US health care delivery is one more symptom of a broken and dysfunctional non-system.
Billy has severe COPD and is on multiple medications. Going out to pick up the morning paper, he trips, falls, becomes confused and can't respond logically to questions from a bystander. 911 is called and arrives. No family members are present. No medical information is available. He's transported to the hospital where it takes 3 hours to track down a partial medical history and an advance directive. There is a delay in recognizing internal bleeding until it's discovered that warfarin is one of his medications. Billy is unfortunate he lives in a state not using smart card technology.
The smart card has been around for a few decades and is in wide use in Germany, France, Taiwan and several other countries. Biometrics and other security measures have been developed to comply with patient privacy regulations. The VA hospitals are using a smart card system successfully. Other health smart card companies are competing for this potentially large market.
There are state wide and even nation wide efforts to have registries for advance directives and POLST forms in order to make them available on an emergent basis. But we are a mobile society. Individual state registries can become redundant, expensive, and hard to maintain. Oregon has the most advanced state registry for POLST forms but that is just one state. Smart cards will allow each one of us to carry around our own health care information in our wallet or purse. Privacy can be protected with use of a thumbprint. Secure readers can be portable.
The lack of wide use of smart cards in the US health care delivery is one more symptom of a broken and dysfunctional non-system.
Monday, March 4, 2013
A Deadly White Powder
Harry would arrive home from work covered in white powder. He'd shed his clothes in the back hall, his wife dutifully shaking them out before putting them in the laundry. Little did they know they were both being exposed to a deadly dose of asbestos.
At the shipyards, Harry was a boilermaker. Large bags of asbestos would be carried down into the ships being refitted for service in WWII. The bags would be dumped into open barrels and water added to make an asbestos paste. There was little or no outside ventilation so asbestos particles clouded the air. The ship's pipes and boilers were wrapped and coated with asbestos, a great fire retardant but unrecognized environmental hazard.
In 1964, I heard a talk in New York by Dr. Irving Selikoff. He had made the link between asbestos exposure and lung disease in his patients from the shipyards. Selikoff went on to do ground breaking research. From him I learned about mesothelioma, asbestosis and asbestos related lung cancer. Interestingly, all of us who are city dwellers appear to have asbestos fibers in our lungs. Asbestos is basically indestructible. When inhaled it can migrate to the outer reaches of our lungs causing a low grade inflammatory process. A marker of prior asbestos exposure is thickening of the outer lining of the lung (the pleura) visible on a chest X-Ray or CT scan. This change might take 20 or 30 years to develop and doesn't cause a problem per se.
Harry's wife did show thickening of the pleura but never had symptoms or problems with it - except the worry that she was at an increased risk for lung cancer or cancer of the pleura (mesothelioma). Harry and many other shipyard workers weren't so fortunate. Harry, a non-smoker, began having a cough and chest pains in his 60's, long after his initial asbestos exposure. An evaluation revealed fluid around the left lung and marked irregular thickening of the pleura. Despite all attempts at treatment, Harry passed away from the pleural cancer, mesothelioma.
Many of Harry's co-workers were smokers. Almost half of them developed lung cancer. There's a multiplying effect on cancer causation between asbestos and tobacco exposure. Some other co-workers developed a diffuse scarring of the lung (pulmonary fibrosis) or a mesothelioma.
In the early 1970's I wrote to one of the asbestos manufacturers complaining about their advertisement stating that "with asbestos your life is safer". The letter I got back was quite hostile and defensive. It took time and litigation to achieve improved occupational safety measures.
It's interesting there are still law firms trolling for patients with asbestos related diseases, but most of the heavy asbestos exposures from mining and the shipyards are, thankfully, a thing of the past.
At the shipyards, Harry was a boilermaker. Large bags of asbestos would be carried down into the ships being refitted for service in WWII. The bags would be dumped into open barrels and water added to make an asbestos paste. There was little or no outside ventilation so asbestos particles clouded the air. The ship's pipes and boilers were wrapped and coated with asbestos, a great fire retardant but unrecognized environmental hazard.
In 1964, I heard a talk in New York by Dr. Irving Selikoff. He had made the link between asbestos exposure and lung disease in his patients from the shipyards. Selikoff went on to do ground breaking research. From him I learned about mesothelioma, asbestosis and asbestos related lung cancer. Interestingly, all of us who are city dwellers appear to have asbestos fibers in our lungs. Asbestos is basically indestructible. When inhaled it can migrate to the outer reaches of our lungs causing a low grade inflammatory process. A marker of prior asbestos exposure is thickening of the outer lining of the lung (the pleura) visible on a chest X-Ray or CT scan. This change might take 20 or 30 years to develop and doesn't cause a problem per se.
Harry's wife did show thickening of the pleura but never had symptoms or problems with it - except the worry that she was at an increased risk for lung cancer or cancer of the pleura (mesothelioma). Harry and many other shipyard workers weren't so fortunate. Harry, a non-smoker, began having a cough and chest pains in his 60's, long after his initial asbestos exposure. An evaluation revealed fluid around the left lung and marked irregular thickening of the pleura. Despite all attempts at treatment, Harry passed away from the pleural cancer, mesothelioma.
Many of Harry's co-workers were smokers. Almost half of them developed lung cancer. There's a multiplying effect on cancer causation between asbestos and tobacco exposure. Some other co-workers developed a diffuse scarring of the lung (pulmonary fibrosis) or a mesothelioma.
In the early 1970's I wrote to one of the asbestos manufacturers complaining about their advertisement stating that "with asbestos your life is safer". The letter I got back was quite hostile and defensive. It took time and litigation to achieve improved occupational safety measures.
It's interesting there are still law firms trolling for patients with asbestos related diseases, but most of the heavy asbestos exposures from mining and the shipyards are, thankfully, a thing of the past.
Friday, February 15, 2013
Death by Cessation of Fluids and Nutrition
If you haven't seen the movie, "Amour", but are planning to, you might want to skip this commentary - but by all means do go!
It starts and ends with love, but not in Hollywood's usual youthful romantic fashion. It also starts and ends with death after much caring, love and suffering. The agonizing toll on the patient and caregiver are equally dramatized in the stark manner of Michael Haneke the Austrian director.
The setting is mundane in the apartment of two aging French musicians. The scenes are quiet, domestic, loving and free of a background music score. As the wife suffers from a series of strokes, her mind and will to live erode. Was it reasonable that she tried to commit suicide? Was it OK for her to make her husband promise never to take her back to the hospital? Could the daughter have been more supportive? What happens as the loving caregiver is finally at his wits end?
Some common measures hoping for improvement were tried: rehab, second opinions, home health aids (one fired), a hospital bed, etc. But both the loving husband and wife had to endure the agony of progressive physical decline - no doubt with accompanying situational depression.
The ending is stark and sad. The husband could see no other way out. How often is the act he committed actually carried out by the loving spouse? We'll never know. . "Amour" portrays this in what feels like real-time to the viewer.
I felt so sad in seeing death handled basically by two aging individuals on their own. There was no home hospice care, no palliative care consultation, and no discussion of death by voluntary cessation of fluids and nutrition (VSED). Dying by VSED deserves more understanding and discussion. Quill and Byock have proposed clinical and ethical guidelines with the caveats to be aware of - coercion, abuse, lack of informed consent, depression, etc. Also, they point out the need for patients, families and providers to have continuing and clarifying discussions - all to allow wishes and dignity of the patient to be honored. "Amour" tackles these in a way that leaves us with lingering doubts and frustration. We have questions about the choices made, yet we're left with undeniable admiration for the loving and dying couple.
A more common scenario happened to my father at the end. I remember him at age 94 basically slowing eating, beginning to losing weight and becoming partially delusional. He then slowed fluid intake but would accept sips of fluids plus mouth care. It seems to me that this was simply old age at its pinnacle with the body wearing out and dying - not really an example of VSED. There would have been no benefit for providing fluids or tube feeding, a means of prolonging dying rather than prolonging life. He died peacefully without the need for diapers or messy body care. We played bridge in his room keeping him company in his peaceful coma. I heard his last breath from the cot beside his bed.
VSED need not be the slippery slope toward euthanasia some might think, but with the care outlined by ethicists and palliative care experts like Quill and Byock, there is hope that many options will be available to us at the end. After all, it is our life, our body, and we all have a time to die.
It starts and ends with love, but not in Hollywood's usual youthful romantic fashion. It also starts and ends with death after much caring, love and suffering. The agonizing toll on the patient and caregiver are equally dramatized in the stark manner of Michael Haneke the Austrian director.
The setting is mundane in the apartment of two aging French musicians. The scenes are quiet, domestic, loving and free of a background music score. As the wife suffers from a series of strokes, her mind and will to live erode. Was it reasonable that she tried to commit suicide? Was it OK for her to make her husband promise never to take her back to the hospital? Could the daughter have been more supportive? What happens as the loving caregiver is finally at his wits end?
Some common measures hoping for improvement were tried: rehab, second opinions, home health aids (one fired), a hospital bed, etc. But both the loving husband and wife had to endure the agony of progressive physical decline - no doubt with accompanying situational depression.
The ending is stark and sad. The husband could see no other way out. How often is the act he committed actually carried out by the loving spouse? We'll never know. . "Amour" portrays this in what feels like real-time to the viewer.
I felt so sad in seeing death handled basically by two aging individuals on their own. There was no home hospice care, no palliative care consultation, and no discussion of death by voluntary cessation of fluids and nutrition (VSED). Dying by VSED deserves more understanding and discussion. Quill and Byock have proposed clinical and ethical guidelines with the caveats to be aware of - coercion, abuse, lack of informed consent, depression, etc. Also, they point out the need for patients, families and providers to have continuing and clarifying discussions - all to allow wishes and dignity of the patient to be honored. "Amour" tackles these in a way that leaves us with lingering doubts and frustration. We have questions about the choices made, yet we're left with undeniable admiration for the loving and dying couple.
A more common scenario happened to my father at the end. I remember him at age 94 basically slowing eating, beginning to losing weight and becoming partially delusional. He then slowed fluid intake but would accept sips of fluids plus mouth care. It seems to me that this was simply old age at its pinnacle with the body wearing out and dying - not really an example of VSED. There would have been no benefit for providing fluids or tube feeding, a means of prolonging dying rather than prolonging life. He died peacefully without the need for diapers or messy body care. We played bridge in his room keeping him company in his peaceful coma. I heard his last breath from the cot beside his bed.
VSED need not be the slippery slope toward euthanasia some might think, but with the care outlined by ethicists and palliative care experts like Quill and Byock, there is hope that many options will be available to us at the end. After all, it is our life, our body, and we all have a time to die.
Monday, January 21, 2013
Religion and the Doctor
William would come to see me every three months for his COPD (Chronic Obstructive Pulmonary Disease). We would chat about his disease, his meds, and his grief. He had lost his wife a few years back, but after 52 years he found it very hard to be without her.
On one visit he said, "Doctor deMaine, can I tell you something - and promise you won't think I'm crazy?"
"Sure."
"Well, my wife and I always had a favorite restaurant where we'd go for our dinner on Sundays. Let me tell you why I still go there. I wear my old tie and coat and sit in our favorite booth. And I swear that I see her. Her image is perfect, younger, and smiling. She looks beautiful. She doesn't really communicate except with the smile - which seems to me to say that she's waiting for me."
Other patients related different views. A very sweet British lady told me on an office visit that she had been a widow now for six months.
"That's sad," I said. "Do you believe in an afterlife?"
"Of course", she replied.
"How about marriage in Heaven?"
"Yes."
Trying to tie this together I said, "That's wonderful. Perhaps you and your husband can spend eternity together."
She paused, tilted her head, smiled and said, "Well, I might play the field a bit first!"
There are many views of the afterlife that vary from none to quite fanciful. Harvard theologian Huston Smith gave his views in the Ingersoll Lecture called Intimations of Immortality. He explored the existence of an afterlife and the influence of William James. In his lecture he highlighted Swedenborg, the Swedish scientist and theologian. Swedenborg broke away from his Lutheran roots in the 1700's and wrote extensively about the afterlife having great influence on the New England transcendentalists and many others. Also, in Smith's lecture, he discussed the near death experiences in Raymond Moody's book "Life After Life". Theologians generally seem to struggle with what Heaven might really be like, but many less academic folks simply view it as a spiritual extension of this life joyfully meeting up with loved ones and those with shared interests.
Helen Keller with her blindness and deafness was, in those senses, cut off from the world. Yet she was a great student of the Bible and eventually became very influenced by Swedenborg's writings.
"Here was a faith [she says] that emphasized what I felt so keenly -- the separateness between soul and body, between a realm I could picture as a whole and the chaos of fragmentary things and limited physical senses met at every turn . . . As I realized the meaning of what I read, my soul seemed to expand and gain confidence amid the difficulties which beset me. ."
The 1998 movie, What Dreams May Come, gives a vivid and possibly realistic picture of what Heaven and Hell could be like. The film has many parallels with Swedenborg's book, "Heaven and Hell." We are alive, active, useful, on the go and finding a home with those we love.
Mark Twain's irreverent views on religion are highlighted in humorously poignant ways: "Go to Heaven for the climate; go to Hell for the company." Further, from Captain Stormfield's Visit to Heaven, .."Now you just remember this - heaven is as blissful and lovely as it can be; but it's just the busiest place you ever heard of. There ain't any idle people here after the first day. Singing hymns and waving palm branches through all eternity is pretty when you hear about it in the pulpit, but it's as poor a way to put in valuable time as a body could contrive. It would just make a heaven of warbling ignoramuses, don't you see?"
Recently a formerly agnostic Neurosurgeon, Eben Alexander III, published a rather astounding book, "Proof of Heaven." His experiences in the spiritual world while in a coma and near to death are certainly powerful and most difficult to explain away. I'm sure though that some will remain unconvinced. Perhaps true "proof" might trump free will, making us less human.
My education along these lines was when I attended Bryn Athyn College for two years. I was immersed in studies of Plato, Aristotle, and others right up though the age of enlightenment including Swedenborg. The emphasis was that there are two capabilities that make us uniquely human: freedom and rationality. We were charged to wisely apply learning to life - heady stuff for a 20 year old.
So does any of this carry over into medical practice? Since we are all in some sense spiritual beings as well as natural beings, it seems logical for a physician to deal with the whole person, particularly around the time of crisis or death. I'm not one who thinks a chosen few have the "inside path" or die easier than atheists. I had some confirmed non-believers in my care who died comfortably believing that "that was that." They appeared to be good people who had led good lives.
But others want to talk, are afraid, or have regrets. All hospitals now have chaplains. Many ministers, rabbis, imams and priests make frequent hospital and nursing home visits. Doctors of course, need to respect all beliefs and understand boundaries. Although I loved having philosophical and religious discussions with patients, I always tried to approach it from their interest and comfort zone.
One Pulmonologist in the area here would ask patients to pray with him before he did their procedure such as a bronchoscopy. Clearly this was inappropriate and boundaries were violated (his group let him go). Patients can, at times, cross boundaries but the "power differential" is much less. I had one very sweet lady who was so sad I wouldn't make it to Heaven because I hadn't been baptized in her faith!
Spiritual beliefs can be, and in my opinion should be, an important part of the conversation when we communicate our choices about end of life care and also as we are nearing the end of our lives. I encouraged my students, interns and residents to become comfortable with this and to not avoid exploring these areas. Healing and caring can occur on many levels.
On one visit he said, "Doctor deMaine, can I tell you something - and promise you won't think I'm crazy?"
"Sure."
"Well, my wife and I always had a favorite restaurant where we'd go for our dinner on Sundays. Let me tell you why I still go there. I wear my old tie and coat and sit in our favorite booth. And I swear that I see her. Her image is perfect, younger, and smiling. She looks beautiful. She doesn't really communicate except with the smile - which seems to me to say that she's waiting for me."
Other patients related different views. A very sweet British lady told me on an office visit that she had been a widow now for six months.
"That's sad," I said. "Do you believe in an afterlife?"
"Of course", she replied.
"How about marriage in Heaven?"
"Yes."
Trying to tie this together I said, "That's wonderful. Perhaps you and your husband can spend eternity together."
She paused, tilted her head, smiled and said, "Well, I might play the field a bit first!"
There are many views of the afterlife that vary from none to quite fanciful. Harvard theologian Huston Smith gave his views in the Ingersoll Lecture called Intimations of Immortality. He explored the existence of an afterlife and the influence of William James. In his lecture he highlighted Swedenborg, the Swedish scientist and theologian. Swedenborg broke away from his Lutheran roots in the 1700's and wrote extensively about the afterlife having great influence on the New England transcendentalists and many others. Also, in Smith's lecture, he discussed the near death experiences in Raymond Moody's book "Life After Life". Theologians generally seem to struggle with what Heaven might really be like, but many less academic folks simply view it as a spiritual extension of this life joyfully meeting up with loved ones and those with shared interests.
Helen Keller with her blindness and deafness was, in those senses, cut off from the world. Yet she was a great student of the Bible and eventually became very influenced by Swedenborg's writings.
"Here was a faith [she says] that emphasized what I felt so keenly -- the separateness between soul and body, between a realm I could picture as a whole and the chaos of fragmentary things and limited physical senses met at every turn . . . As I realized the meaning of what I read, my soul seemed to expand and gain confidence amid the difficulties which beset me. ."
The 1998 movie, What Dreams May Come, gives a vivid and possibly realistic picture of what Heaven and Hell could be like. The film has many parallels with Swedenborg's book, "Heaven and Hell." We are alive, active, useful, on the go and finding a home with those we love.
Mark Twain's irreverent views on religion are highlighted in humorously poignant ways: "Go to Heaven for the climate; go to Hell for the company." Further, from Captain Stormfield's Visit to Heaven, .."Now you just remember this - heaven is as blissful and lovely as it can be; but it's just the busiest place you ever heard of. There ain't any idle people here after the first day. Singing hymns and waving palm branches through all eternity is pretty when you hear about it in the pulpit, but it's as poor a way to put in valuable time as a body could contrive. It would just make a heaven of warbling ignoramuses, don't you see?"
Recently a formerly agnostic Neurosurgeon, Eben Alexander III, published a rather astounding book, "Proof of Heaven." His experiences in the spiritual world while in a coma and near to death are certainly powerful and most difficult to explain away. I'm sure though that some will remain unconvinced. Perhaps true "proof" might trump free will, making us less human.
My education along these lines was when I attended Bryn Athyn College for two years. I was immersed in studies of Plato, Aristotle, and others right up though the age of enlightenment including Swedenborg. The emphasis was that there are two capabilities that make us uniquely human: freedom and rationality. We were charged to wisely apply learning to life - heady stuff for a 20 year old.
So does any of this carry over into medical practice? Since we are all in some sense spiritual beings as well as natural beings, it seems logical for a physician to deal with the whole person, particularly around the time of crisis or death. I'm not one who thinks a chosen few have the "inside path" or die easier than atheists. I had some confirmed non-believers in my care who died comfortably believing that "that was that." They appeared to be good people who had led good lives.
But others want to talk, are afraid, or have regrets. All hospitals now have chaplains. Many ministers, rabbis, imams and priests make frequent hospital and nursing home visits. Doctors of course, need to respect all beliefs and understand boundaries. Although I loved having philosophical and religious discussions with patients, I always tried to approach it from their interest and comfort zone.
One Pulmonologist in the area here would ask patients to pray with him before he did their procedure such as a bronchoscopy. Clearly this was inappropriate and boundaries were violated (his group let him go). Patients can, at times, cross boundaries but the "power differential" is much less. I had one very sweet lady who was so sad I wouldn't make it to Heaven because I hadn't been baptized in her faith!
Spiritual beliefs can be, and in my opinion should be, an important part of the conversation when we communicate our choices about end of life care and also as we are nearing the end of our lives. I encouraged my students, interns and residents to become comfortable with this and to not avoid exploring these areas. Healing and caring can occur on many levels.
Tuesday, November 13, 2012
Killing 100 Million People
I'm old enough to remember smoking sections on airplanes, smoking in theaters, smoking in the doctor's lounge and even doctors smoking on rounds in the hospital. Once I walked in the room of a patient who was 4 days following the removal of a lung cancer only to find three relatives smoking at his bedside.
In the early 1980's, we petitioned our hospital system to become non-smoking. This was so radical that the hospital attorney stated, "I can't tell my secretary not to smoke at her desk!" It thus was viewed and argued that this was an individual rights issue. Fortunately though, about this time second hand smoke adverse health effects were coming to light. Within a year we became one of the first in the country to become tobacco free.
There was still push back and some contention - even some humorous incidents. I walked into the ICU one afternoon and an RN said, "You're not going to believe what happened. I walked into the call room to have a rest and found it full of smoke with a shadowy figure across the room. So I bolted back to the ICU and called security. When he answered, I told him what happened. There was a moment of silence, then he said, 'I'm sorry, but that was me you saw!'"
The 20th century will be remembered for its 100 million tobacco related deaths in the USA. The BBC has an excellent summary of just how the mechanizing and marketing of the cigarette led to the epidemic of tobacco abuse in the USA and worldwide. Lung cancer was so rare in the early 20th century that medical students might never see a case - and would be called to view an autopsy when lung cancer could be viewed.
Smoking was cleverly and cynically marketed to women as a sign of sophistication and liberation. Remember the ad "You've Come a Long Way Baby?"
So what can we learn? We all do like our rights - to smoke, get fat, drive fast, etc. However these behaviors cost us as a society, and it's problematic how to find the appropriate role of governmental efforts to educate and regulate. But since we all pick up the health care and economic impact, we're all interested parties. It will be interesting to follow the attempts to reverse the obesity epidemic now facing this country which are fairly timid so far.
In the early 1980's, we petitioned our hospital system to become non-smoking. This was so radical that the hospital attorney stated, "I can't tell my secretary not to smoke at her desk!" It thus was viewed and argued that this was an individual rights issue. Fortunately though, about this time second hand smoke adverse health effects were coming to light. Within a year we became one of the first in the country to become tobacco free.There was still push back and some contention - even some humorous incidents. I walked into the ICU one afternoon and an RN said, "You're not going to believe what happened. I walked into the call room to have a rest and found it full of smoke with a shadowy figure across the room. So I bolted back to the ICU and called security. When he answered, I told him what happened. There was a moment of silence, then he said, 'I'm sorry, but that was me you saw!'"
The 20th century will be remembered for its 100 million tobacco related deaths in the USA. The BBC has an excellent summary of just how the mechanizing and marketing of the cigarette led to the epidemic of tobacco abuse in the USA and worldwide. Lung cancer was so rare in the early 20th century that medical students might never see a case - and would be called to view an autopsy when lung cancer could be viewed.
Smoking was cleverly and cynically marketed to women as a sign of sophistication and liberation. Remember the ad "You've Come a Long Way Baby?"
So what can we learn? We all do like our rights - to smoke, get fat, drive fast, etc. However these behaviors cost us as a society, and it's problematic how to find the appropriate role of governmental efforts to educate and regulate. But since we all pick up the health care and economic impact, we're all interested parties. It will be interesting to follow the attempts to reverse the obesity epidemic now facing this country which are fairly timid so far.
Monday, October 15, 2012
Should We Ration Health Care in the USA?
There is a serious cost problem in USA health care which no one denies. Yet when it comes to suggested solutions, there is a wide divergence of opinion. Attempts to use experts and evidence based guidelines for care are somehow viewed as government interfering with decisions which should be between the doctor and her patient. States and insurance schemes have made varying attempts to deal with this. The Oregon Health Plan is a good example of an attempt to match funding with needed care. Unfortunately to date the need has far outstripped funding. But Oregon had an interesting idea. Why not bring physicians, consumers, advocates, interested groups and see where limited dollars should be spent - basically where can we get the best "bang for the buck" in a given population. Long lists of preventable and treatable illness were made up and, in a transparent way, coverage was designed for best use of the dollars. This is what I would call rational rationing. We only have so much money for health care (currently up to 17% of GDP), it's not infinite, and it's already impinging out ability to funds schools, infrastructure, etc.
We are spending 50% more in health care services in the USA than other developed nations, yet our longevity and health outcomes are equivalent to Slovenia and Costa Rica, less developed nations. About 35 million people in our country have no medical insurance. It was suggested in political debates that they can go to any emergency room, but that of course is delayed and fragmented care which actually drives up costs. I saw a 40 year old waitress in my office after she coughed up blood. Her diagnosis was lung cancer. There was no funding for radiation treatments or chemotherapy or even palliative care. I felt so badly when I couldn't effectively guide her care.
So it's pretty obvious that we do ration care in the USA. We do it by ability to pay, with a poor safety net for those unable to pay. Several Presidents beginning with Theodore Roosevelt have tried to reform health care without success. The current reforms, essentially modeled after those in Massachusetts promoted by then Governor Romney, are now under attack by none other than Romney himself. Romney decries the attempts to control Medicare costs in the Affordable Health Care Act (now called Obamacare).
If you're interested in viewing a thorough debate on the subject of end-of-life rationing please click on this link. A live audience is polled before and after to see which debating team "won."
We are spending 50% more in health care services in the USA than other developed nations, yet our longevity and health outcomes are equivalent to Slovenia and Costa Rica, less developed nations. About 35 million people in our country have no medical insurance. It was suggested in political debates that they can go to any emergency room, but that of course is delayed and fragmented care which actually drives up costs. I saw a 40 year old waitress in my office after she coughed up blood. Her diagnosis was lung cancer. There was no funding for radiation treatments or chemotherapy or even palliative care. I felt so badly when I couldn't effectively guide her care.
So it's pretty obvious that we do ration care in the USA. We do it by ability to pay, with a poor safety net for those unable to pay. Several Presidents beginning with Theodore Roosevelt have tried to reform health care without success. The current reforms, essentially modeled after those in Massachusetts promoted by then Governor Romney, are now under attack by none other than Romney himself. Romney decries the attempts to control Medicare costs in the Affordable Health Care Act (now called Obamacare).
If you're interested in viewing a thorough debate on the subject of end-of-life rationing please click on this link. A live audience is polled before and after to see which debating team "won."
Friday, October 5, 2012
Cancer Can't
At a recent presentation to our Foundation Board a Harvard trained Oncologist presented this as an opening statement in his overview of cancer. It seems worth sharing to show we may have choices in dealing with the shocking words, "You have cancer of ... and ... your options are."
What Cancer Can't Do
It cannot cripple love
It cannot shatter hope
It cannot corrode faith
It cannot destroy peace
It cannot kill friendship
It cannot suppress memories
It cannot silence courage
It cannot steal eternal life
It cannot conquer the spirit
~~Author Unknown
What Cancer Can't Do
It cannot cripple love
It cannot shatter hope
It cannot corrode faith
It cannot destroy peace
It cannot kill friendship
It cannot suppress memories
It cannot silence courage
It cannot steal eternal life
It cannot conquer the spirit
~~Author Unknown
Monday, September 3, 2012
A Visitor in the Operating Room
It was Trevor's first weekend to relax since moving to Seattle. He was out in a park walking Bailey, his year old lab, when his pager unexpectedly beeped. He called in to the operating room office, where the frantic head nurse told him he had to come in. The scheduled anesthesiologist was very ill with the flu, and no one else was available. He had to come in for at least two cases, perhaps more.
Trevor pleaded, "Can't you find anyone else, it's my first weekend off, and I doubt if I can find anyone to watch Bailey."
"Sorry, we need you - now!", came the curt reply.
Trevor called his only friend so far but got no reply. He hadn't had much contact with neighbors yet, so didn't think he could ask them to take care of Bailey. So having no other choice, he packed Bailey along with water and dog food into his Subaru hoping that Bailey wouldn't mind hanging out in the car.
Bailey barked annoyingly as Trevor parked the car in the shade, cracked the windows a bit, and headed for the OR. The case was easy and lasted about an hour. Trevor headed quickly out to the car finding Bailey trying to dismantle it. There were scratch marks on the door and a tear in the seat cover. This just wasn't working.
So Trevor walked Bailey, now happy around to the back of the hospital, entered the service entrance and took the back service elevator which came up just outside the anesthesia call room. He stayed with Bailey making sure he had water and food and a comfortable pillow, then was called in for the next case. Bailey seemed content to wait for him.
The case was an appendectomy. The patient was anesthetized in the usual fashion and Trevor settled in to watch the monitors and patient while the surgeon went to work. Strangely he felt pressure and a cold wet sensation on his left leg. Looking down with dread he saw Bailey looking up with a happy face and wagging tail. The OR nurse screeched, "Where in the hell did that dog come from? Get him out of here."
The surgeon didn't miss a beat, "At least give him a mask and dog booties."
The patient, of course, was peacefully oblivious.
The dog was watched by security, who cared for him until Trevor could leave, red faced and worried about repercussions. I'm happy to report that the unsuspecting patient did well, Trevor kept his job, and that Bailey probably wondered what the fuss was all about.
Of course the hospital administrators had their fur ruffled, but were happy that no one leaked the story to the press.
Comment: True story!
Trevor pleaded, "Can't you find anyone else, it's my first weekend off, and I doubt if I can find anyone to watch Bailey."
"Sorry, we need you - now!", came the curt reply.
Trevor called his only friend so far but got no reply. He hadn't had much contact with neighbors yet, so didn't think he could ask them to take care of Bailey. So having no other choice, he packed Bailey along with water and dog food into his Subaru hoping that Bailey wouldn't mind hanging out in the car.
Bailey barked annoyingly as Trevor parked the car in the shade, cracked the windows a bit, and headed for the OR. The case was easy and lasted about an hour. Trevor headed quickly out to the car finding Bailey trying to dismantle it. There were scratch marks on the door and a tear in the seat cover. This just wasn't working.
So Trevor walked Bailey, now happy around to the back of the hospital, entered the service entrance and took the back service elevator which came up just outside the anesthesia call room. He stayed with Bailey making sure he had water and food and a comfortable pillow, then was called in for the next case. Bailey seemed content to wait for him.
The case was an appendectomy. The patient was anesthetized in the usual fashion and Trevor settled in to watch the monitors and patient while the surgeon went to work. Strangely he felt pressure and a cold wet sensation on his left leg. Looking down with dread he saw Bailey looking up with a happy face and wagging tail. The OR nurse screeched, "Where in the hell did that dog come from? Get him out of here."
The surgeon didn't miss a beat, "At least give him a mask and dog booties."
The patient, of course, was peacefully oblivious.
The dog was watched by security, who cared for him until Trevor could leave, red faced and worried about repercussions. I'm happy to report that the unsuspecting patient did well, Trevor kept his job, and that Bailey probably wondered what the fuss was all about.
Of course the hospital administrators had their fur ruffled, but were happy that no one leaked the story to the press.
Comment: True story!
Monday, August 6, 2012
Dad's Old-School Medical Practice
In order to be with my Dad, after dinner I'd go on house calls with him. We'd drive to parts of town I'd never seen, and using the car's spotlight we'd search out the right house number, often with no small difficulty. I'd usually wait in the car. He hefted up his rather large mysterious black doctor's bag and headed for the door. He spent about a half hour listening and examining the patient. On return, I always asked him if he gave the patient a "shot". Sometimes he did - a diuretic, or B12. Sometimes it was cortisone into an inflamed joint. Once he explained to me that when washing his hands in the patient's bathroom, that he'd occasionally peek into the medicine cabinet to find out what array of medicines the patient might really be taking.
Dad loved doing obstetrics so we'd have to plan family vacations around his patients' due dates. He said he really felt his age when he was delivering babies from those who he delivered some 20 years previously. Then he would follow the kids along handling their routine care and even being there to give open drop ether for their tonsillectomies. Polio was the big fear during the summer epidemics.
During dinner time, Mom was very protective of Dad's time for the meal. She handled fevers over the phone, walked patients through the care of scrapes and cuts, and would tell white lies, "I'm sorry he's not home yet. I'm sure he can call you back in a half hour." When it was turning into an emergency, she'd say, "Oh, his car just turned into the driveway, hang on." Needless to say, we all learned to eat fast.
We lived a middle class existence in a comfortable but far from fancy house in our mid-west city. Dad's friends were specialists who had fancier homes and cars. He finally had funds to join a golf club in his later years, but Mom refused to eat there because of the club's racial and religious discriminatory practices.
As Dad aged, he decided to drop OB so his practice gradually became geriatrics and nursing home rounding. He kept this up until his mid-70's. He'd make social calls for his patient's in the hospital, go to memorial services, and even be a speaker at the request of a few families. One thing he never forgot to do was to send a letter of condolence to the families. In his 90's he ended up in an electric wheelchair in a nursing home due to crippling spinal stenosis. Several former patients were also there. Dad would go by, chat, and pat them on the arm. He never quit making rounds.
Comment: The above stories are memories from a time gone by and may seem impossibly old-school. But have we lost something in our transition to high-tech care? Can we find ways to rekindle high-touch care and learn some lessons from the past?
Dad loved doing obstetrics so we'd have to plan family vacations around his patients' due dates. He said he really felt his age when he was delivering babies from those who he delivered some 20 years previously. Then he would follow the kids along handling their routine care and even being there to give open drop ether for their tonsillectomies. Polio was the big fear during the summer epidemics.
During dinner time, Mom was very protective of Dad's time for the meal. She handled fevers over the phone, walked patients through the care of scrapes and cuts, and would tell white lies, "I'm sorry he's not home yet. I'm sure he can call you back in a half hour." When it was turning into an emergency, she'd say, "Oh, his car just turned into the driveway, hang on." Needless to say, we all learned to eat fast.
We lived a middle class existence in a comfortable but far from fancy house in our mid-west city. Dad's friends were specialists who had fancier homes and cars. He finally had funds to join a golf club in his later years, but Mom refused to eat there because of the club's racial and religious discriminatory practices.
As Dad aged, he decided to drop OB so his practice gradually became geriatrics and nursing home rounding. He kept this up until his mid-70's. He'd make social calls for his patient's in the hospital, go to memorial services, and even be a speaker at the request of a few families. One thing he never forgot to do was to send a letter of condolence to the families. In his 90's he ended up in an electric wheelchair in a nursing home due to crippling spinal stenosis. Several former patients were also there. Dad would go by, chat, and pat them on the arm. He never quit making rounds.
Comment: The above stories are memories from a time gone by and may seem impossibly old-school. But have we lost something in our transition to high-tech care? Can we find ways to rekindle high-touch care and learn some lessons from the past?
Monday, July 30, 2012
The Lie That Won't Die
One would think that the "Lie of the Year" of 2009 as judged by PolitiFact wouldn't continue to resurface, but it has repeatedly. The lie was, as you may remember, that Death Panels would convene under health care reform that would allow the government to judge who would live and die based on their value to society. People had some fun mocking the outrageous lie, but the scary part is that a fair number of people believed it and continue to believe some version. It recently resurfaced in criticisms of the proposed Independent Pay Advisory Board in the Affordable Health Care Act. The IPAB is prohibited by law from rationing, yet Palin and others state that it's the slippery slope toward euthanasia. Please read the background commentary of Diana J. Mason, PhD, RN published in JAMA.
All of us need to be aware of the repeated attempts to blow up meaningful health care reform using misinformation. If a lie is repeated often enough, it often takes on a life of its own. So, if you want an easy way to better inform yourself, consider listening to Coursera lectures by Ezekiel Emmanuel from the University of Pennsylvania.
All of us need to be aware of the repeated attempts to blow up meaningful health care reform using misinformation. If a lie is repeated often enough, it often takes on a life of its own. So, if you want an easy way to better inform yourself, consider listening to Coursera lectures by Ezekiel Emmanuel from the University of Pennsylvania.
Wednesday, May 16, 2012
When It Doesn't Make Sense
As doctors in training, we learn to think in patterns of symptoms and can often use "clinical judgement" to fit a patient's presenting symptoms into a diagnosis. This generally works well, until we are presented with an unfamiliar pattern. For example, in the early 80's I saw a 60 year old shoe salesman with fatigue and a low grade fever. He had general malaise and some muscle weakness. His exam and initial blood work was unrevealing except he was mildly anemic and his sed rate was elevated. A search for cancer and infection unrevealing. So my next thought was polymyalgia rheumatica, an autoimmune illness associated with inflammation of medium sized arteries. I sent him to a surgeon for a temporal artery biopsy which was negative.
About this time he started to get a cough and the chest X-Ray showed a hazy pattern of change. I knew the symptoms yet had not yet encountered HIV. He was one of the first cases in our State, but likely we had all missed the boat with similar patients. Our pattern thinking generally works clinically, but it isn't a very good way to ferret out a new or unexpected disease. I never thought to ask the right questions or to have a high index of suspicion. The patient went on to full blown AIDS and died as most patients did in the early days of the HIV epidemic. So sad.
In another situation, I saw a young man with onset of shaking chills and fever in my clinic. I immediately thought of a viral or bacterial infection trying to narrow down the possible causes. But then the patient made the diagnosis for me, "Hey doc, you know I felt just like this when I had malaria in Vietnam." It was exciting to see his blood smear with parasites in the red blood cells when I went to the lab, but I certainly again felt humbled when thinking about the patterns and short cuts that we tend to use in day to day medicine.
Some of the best primary care physicians I know seem to have a sixth sense when the patient's story and exam just don't seem to add up. One GP friend called me, "Jim, my patient was diagnosed with pneumonia in Europe but is home now and I don't think she should be this short of breath." It turned out the patient had survived a major pulmonary embolus and still had dangerous clot in her legs. As a pulmonologist, I immediately was thinking of air travel and pulmonary emboli. My GP friend wasn't, he just knew that things didn't sound right and he correctly exercised his "high index of suspicion" that he needed to bounce this off a specialist. Believe me, I always payed attention when he called.
When I was a resident at a VA Hospital, we had a long term patient with a knee joint infection. He had been there for a month and a staph infection had now turned into an even more difficult pseudomonas infection requiring fairly toxic IV medications plus joint drainage. As that knee slowly resolved, the other knee joint became septic. As in the other cases, this just didn't make sense. My intern sent the patient down for X-Rays and then checked the bedside table. Sure enough, there was a vial of cloudy infected urine along with syringes and needles the patient was using to self inject his knees. The rare diagnosis of Munchausen's Syndrome became apparent, a psychiatric disorder where the patient will induce, suffer and endure a variety of medical and surgical illnesses in their abnormal mental state.
I've always found medicine humbling. There's far more knowledge there than we can absorb, the patients are endlessly varying in their presentations, and there are so many unknowns about the illnesses they have. We tend to use such terms as "essential, idiopathic, or primary" as if somehow labeling a condition adds to its understanding. With the further explosion of knowledge in genetics and bioengineering it brings to mind the lesson I first learned in medical school: "the questions in medicine never change but every few years the answers do."
About this time he started to get a cough and the chest X-Ray showed a hazy pattern of change. I knew the symptoms yet had not yet encountered HIV. He was one of the first cases in our State, but likely we had all missed the boat with similar patients. Our pattern thinking generally works clinically, but it isn't a very good way to ferret out a new or unexpected disease. I never thought to ask the right questions or to have a high index of suspicion. The patient went on to full blown AIDS and died as most patients did in the early days of the HIV epidemic. So sad.
In another situation, I saw a young man with onset of shaking chills and fever in my clinic. I immediately thought of a viral or bacterial infection trying to narrow down the possible causes. But then the patient made the diagnosis for me, "Hey doc, you know I felt just like this when I had malaria in Vietnam." It was exciting to see his blood smear with parasites in the red blood cells when I went to the lab, but I certainly again felt humbled when thinking about the patterns and short cuts that we tend to use in day to day medicine.
Some of the best primary care physicians I know seem to have a sixth sense when the patient's story and exam just don't seem to add up. One GP friend called me, "Jim, my patient was diagnosed with pneumonia in Europe but is home now and I don't think she should be this short of breath." It turned out the patient had survived a major pulmonary embolus and still had dangerous clot in her legs. As a pulmonologist, I immediately was thinking of air travel and pulmonary emboli. My GP friend wasn't, he just knew that things didn't sound right and he correctly exercised his "high index of suspicion" that he needed to bounce this off a specialist. Believe me, I always payed attention when he called.
When I was a resident at a VA Hospital, we had a long term patient with a knee joint infection. He had been there for a month and a staph infection had now turned into an even more difficult pseudomonas infection requiring fairly toxic IV medications plus joint drainage. As that knee slowly resolved, the other knee joint became septic. As in the other cases, this just didn't make sense. My intern sent the patient down for X-Rays and then checked the bedside table. Sure enough, there was a vial of cloudy infected urine along with syringes and needles the patient was using to self inject his knees. The rare diagnosis of Munchausen's Syndrome became apparent, a psychiatric disorder where the patient will induce, suffer and endure a variety of medical and surgical illnesses in their abnormal mental state.
I've always found medicine humbling. There's far more knowledge there than we can absorb, the patients are endlessly varying in their presentations, and there are so many unknowns about the illnesses they have. We tend to use such terms as "essential, idiopathic, or primary" as if somehow labeling a condition adds to its understanding. With the further explosion of knowledge in genetics and bioengineering it brings to mind the lesson I first learned in medical school: "the questions in medicine never change but every few years the answers do."
Tuesday, May 15, 2012
Trial of a Cardiologist
I went to court recently sitting quietly in the gallery listening to the testimony of two designated experts who criticized the care of a cardiologist (admired in local medical circles for his brilliance and excellent care of patients). The case on first glance didn't look very good for this defendant. The patient had presented to the ER with atypical chest pain, was admitted and evaluated with an exercise test and nuclear medicine heart scanning but subsequently died of a massive heart attack four months later.
The two plaintiff experts questioned the interpretation of the tests (read as within normal limits) and said that the care did not meet the accepted standard of care. They both felt that the patient should have had a coronary angiogram done to further rule in or rule out coronary narrowing. They noted that the autopsy showed narrowing of two major coronary arteries and was the cause of death.
I later asked one of the attorneys just how they could identify and contract with experts in the field to testify against doctors. He said, "Oh, that's no problem. There are web sites where a wide variety of experts can be found."
But it gets expensive. Given that taking depositions and flying in experts is so expensive, a case must be worth more than $250,000 for a plaintiffs attorney to even consider going ahead with a law suit. So with their 40% contingency fee they might receive $100,000 but spend much of that just paying their experts and other costs. So they hope for the "home run case" like a wrongful death to clear more than $1M after expenses.
The defendant was about 40, well trained and experienced in interventional cardiology - doing heart caths, stents, and angioplasty. He elected not to do an angiogram based on established national guidelines. Also, importantly neither the patient or primary care doctor contacted him after discharge from the hospital. Over those four months the chest pain intermittently recurred, but no one contacted the cardiologist about this worrisome issue.
The first expert quibbled about minor EKG findings, "high normal" troponins, and the quality of the stress test and nuclear medicine scan looking for ischemia following the Bruce protocol testing. However he was circular in his reasoning and very unconvincing. Although he was on the clinical cardiology faculty of a medical school and was board certified, he was never trained in the skills of actually doing a coronary angiogram.
The second expert flew in from the East Coast, had Ivy credentials, but was unaware that nuclear medicine specialists can be certified to carry out nuclear cardiac stress imaging. He was also never trained in invasive cardiac procedures such as coronary arteriography. This expert on cross examination admitted that his initial bills for this case were already more than $11,000 and this did not include recent meetings with the attorney plus the two days billing for his trip to testify in Washington State. He also admitted that he has testified in 35 different states in multiple lawsuits almost always for the plaintiff.
I sat there thinking, "Why do we try to do very difficult malpractice suits this way? Does the jury have the ability to really sort out the technical questions about atypical chest pain, when they hear conflicting expert witnesses?"
I certainly feel sorry for the wife and adult children for the tragic loss of their father. But is someone always to blame? Hindsight is always easy. Sure, a lot of patients might have had coronary angiography in this setting, but is that because it's really indicated or are there other factors like financial incentives? Our Cardiologist would have been able to charge a nice fee if he did the procedure, but he followed his best judgment using accepted guidelines. Somehow, the primary care doctor was never named in the suit though a hospitalist and the nuclear medicine doctor were - probably a bad omission by the plaintiffs attorney.
It was impossible to read the jury. The 13 men and women were giving up nearly 3 weeks of their lives to serve a citizen's duty. They were attentive and asked some interesting questions when given the opportunity. The judge kept the courtroom civil, yet the tension was high.
After adjournment for the day, I asked one attorney about the cost of bringing in expert witnesses. She said it was a career for some experts, "I know of a chiropractor who brings in more than $500,000 a year by testifying. It's common to charge $4-500/hour, but some local Orthopedists charge up to $1200 per hour and want to be paid in advance!"
Of course it's hard to get doctors to testify against doctors. We've all made mistakes and who are we to point the finger? So it's common to try to find experts from a different area - but 3000 miles such as our second expert seems a bit extreme, also he must be accumulating lots of frequent flyer miles from testifying in 35 states. I wonder how the jury will deal with this "hired gun".
I plan to go back to hear one of the two defense witnesses in a day or two. They will no doubt be local interventional Cardiologists who will support the care given.
I'm not sure though that I want to hear the outcome of this case. It seems that winners and losers come with lots of caveats. A man is dead from a heart attack. The family will continue to grieve. The cardiologist may have a black mark on his record, but might "win" if not found at fault. But doesn't the jury have to find somebody at fault? I would love to hear their deliberations. The fly-in experts can't really feel very good about the work they're doing though they're happy with the dollar flow. The lawyers on both sides are simply doing their job. The plaintiffs attorney is betting big on a huge settlement. The defense attorneys are billing the insurance companies on an hourly rate, so they don't mind the time spent - and likely feel good about trying their best to represent this client. Insurance rates will likely remain high.
My question for is as follows: Is there a better, more fair, less costly, politically feasible, and just way to handle a malpractice case such as this? Mediation has already failed and the two sides can't come to an agreement. How should we ask our courts and law makers to deal with this? Some countries don't use juries for civil lawsuits like this one. Any thoughts?
Comment: According to Wikipedia , "The extra cost of malpractice lawsuits is a proportion of health spending in both the U.S. (1.7% in 2002) and Canada (0.27% in 2001). In Canada the total cost of settlements, legal fees, and insurance comes to $4 per person each year, but in the United States it is over $60. Average payouts to American plaintiffs were $265,103, while payouts to Canadian plaintiffs were somewhat higher, averaging $309,417. However, malpractice suits are far more common in the U.S., with 350% more suits filed each year per person. While malpractice costs are significantly higher in the U.S., they make up only a small proportion of total medical spending. The total cost of defending and settling malpractice lawsuits in the U.S. in 2004 was over $28 billion. Critics say that defensive medicine consumes up to 9% of American healthcare expenses."
The two plaintiff experts questioned the interpretation of the tests (read as within normal limits) and said that the care did not meet the accepted standard of care. They both felt that the patient should have had a coronary angiogram done to further rule in or rule out coronary narrowing. They noted that the autopsy showed narrowing of two major coronary arteries and was the cause of death.
I later asked one of the attorneys just how they could identify and contract with experts in the field to testify against doctors. He said, "Oh, that's no problem. There are web sites where a wide variety of experts can be found."
But it gets expensive. Given that taking depositions and flying in experts is so expensive, a case must be worth more than $250,000 for a plaintiffs attorney to even consider going ahead with a law suit. So with their 40% contingency fee they might receive $100,000 but spend much of that just paying their experts and other costs. So they hope for the "home run case" like a wrongful death to clear more than $1M after expenses.
The defendant was about 40, well trained and experienced in interventional cardiology - doing heart caths, stents, and angioplasty. He elected not to do an angiogram based on established national guidelines. Also, importantly neither the patient or primary care doctor contacted him after discharge from the hospital. Over those four months the chest pain intermittently recurred, but no one contacted the cardiologist about this worrisome issue.
The first expert quibbled about minor EKG findings, "high normal" troponins, and the quality of the stress test and nuclear medicine scan looking for ischemia following the Bruce protocol testing. However he was circular in his reasoning and very unconvincing. Although he was on the clinical cardiology faculty of a medical school and was board certified, he was never trained in the skills of actually doing a coronary angiogram.
The second expert flew in from the East Coast, had Ivy credentials, but was unaware that nuclear medicine specialists can be certified to carry out nuclear cardiac stress imaging. He was also never trained in invasive cardiac procedures such as coronary arteriography. This expert on cross examination admitted that his initial bills for this case were already more than $11,000 and this did not include recent meetings with the attorney plus the two days billing for his trip to testify in Washington State. He also admitted that he has testified in 35 different states in multiple lawsuits almost always for the plaintiff.
I sat there thinking, "Why do we try to do very difficult malpractice suits this way? Does the jury have the ability to really sort out the technical questions about atypical chest pain, when they hear conflicting expert witnesses?"
I certainly feel sorry for the wife and adult children for the tragic loss of their father. But is someone always to blame? Hindsight is always easy. Sure, a lot of patients might have had coronary angiography in this setting, but is that because it's really indicated or are there other factors like financial incentives? Our Cardiologist would have been able to charge a nice fee if he did the procedure, but he followed his best judgment using accepted guidelines. Somehow, the primary care doctor was never named in the suit though a hospitalist and the nuclear medicine doctor were - probably a bad omission by the plaintiffs attorney.
It was impossible to read the jury. The 13 men and women were giving up nearly 3 weeks of their lives to serve a citizen's duty. They were attentive and asked some interesting questions when given the opportunity. The judge kept the courtroom civil, yet the tension was high.
After adjournment for the day, I asked one attorney about the cost of bringing in expert witnesses. She said it was a career for some experts, "I know of a chiropractor who brings in more than $500,000 a year by testifying. It's common to charge $4-500/hour, but some local Orthopedists charge up to $1200 per hour and want to be paid in advance!"
Of course it's hard to get doctors to testify against doctors. We've all made mistakes and who are we to point the finger? So it's common to try to find experts from a different area - but 3000 miles such as our second expert seems a bit extreme, also he must be accumulating lots of frequent flyer miles from testifying in 35 states. I wonder how the jury will deal with this "hired gun".
I plan to go back to hear one of the two defense witnesses in a day or two. They will no doubt be local interventional Cardiologists who will support the care given.
I'm not sure though that I want to hear the outcome of this case. It seems that winners and losers come with lots of caveats. A man is dead from a heart attack. The family will continue to grieve. The cardiologist may have a black mark on his record, but might "win" if not found at fault. But doesn't the jury have to find somebody at fault? I would love to hear their deliberations. The fly-in experts can't really feel very good about the work they're doing though they're happy with the dollar flow. The lawyers on both sides are simply doing their job. The plaintiffs attorney is betting big on a huge settlement. The defense attorneys are billing the insurance companies on an hourly rate, so they don't mind the time spent - and likely feel good about trying their best to represent this client. Insurance rates will likely remain high.
My question for is as follows: Is there a better, more fair, less costly, politically feasible, and just way to handle a malpractice case such as this? Mediation has already failed and the two sides can't come to an agreement. How should we ask our courts and law makers to deal with this? Some countries don't use juries for civil lawsuits like this one. Any thoughts?
Comment: According to Wikipedia , "The extra cost of malpractice lawsuits is a proportion of health spending in both the U.S. (1.7% in 2002) and Canada (0.27% in 2001). In Canada the total cost of settlements, legal fees, and insurance comes to $4 per person each year, but in the United States it is over $60. Average payouts to American plaintiffs were $265,103, while payouts to Canadian plaintiffs were somewhat higher, averaging $309,417. However, malpractice suits are far more common in the U.S., with 350% more suits filed each year per person. While malpractice costs are significantly higher in the U.S., they make up only a small proportion of total medical spending. The total cost of defending and settling malpractice lawsuits in the U.S. in 2004 was over $28 billion. Critics say that defensive medicine consumes up to 9% of American healthcare expenses."
Monday, April 16, 2012
I'm Sorry I Have to Sue You
I felt sad when I went to make rounds in the hospital. One of my patients, a colleague, had been readmitted in poor condition for recurrence of a primary lung sarcoma. I spent a few minutes examining Dennis and chatting. He then, with a quizzical look, said, "Jim, I'm going to have to sue you. I know I'm dying. My wife Alice and the kids are still pretty young." He saw my look of surprise and added, "You know, I don't have much life insurance or other very significant funds for them to live on. It's nothing personal. I know you've given me good care, but my wife is upset and tends to blame you for the outcome. I guess the hospital and others will be named." There wasn't much more for me to say at the time except, "Dennis I can find another attending for you if you'd like." He replied, "No, I want to stay with you."
Dennis was a well liked family doctor. About five years earlier a "coin lesion" was discovered on a chest X-Ray. This 2cm spot in the right upper lobe had a smooth rounded border and didn't contain calcium. A CT scan showed no enlarged lymph nodes and no other spots elsewhere. A needle biopsy of the spot was not diagnostic. We knew the spot was new because an X-Ray five years earlier was normal. He hadn't traveled to an area where Valley Fever or other fungal infections were common.
At surgery, the right upper lobe was removed along with local lymph nodes. The lesion turned out to be a primary lung sarcoma, a quite unusual type of lung cancer. One of the lymph nodes was positive. We sent Dennis to local experts on sarcoma and several opinions from cancer specialists were obtained. The consensus at that time was that sarcomas don't respond very well to either chemo or radiation therapy, but after further opinions, Dennis had a series of radiation treatments.
After that it was waiting. For three years, there was little change. Then fluid began to accumulate in the right lung cavity and some density in the area of radiation (often radiation changes). I drained the fluid from Dennis' chest several times. No cancer cells were found. After more signs of progression but no proof of recurrence, I sent Dennis to the top academic chest surgeon in the area who admitted Dennis to the hospital. After more conferencing there, he attempted a complete removal of the right lung in order to try to remove all the residual tumor. Dennis had a very stormy post-op course and required ICU care and a ventilator for almost three months before being successfully weaned off. However, the sarcoma was never completely removed, thus still progressing.
He was then transferred back to my hospital where I met with Alice. Somehow I was the focus of her anger about her husbands tragic illness, and extensive suffering especially over the past year with heroic attempts to deal with the recurring sarcoma. We had social service and others involved. To say the least it was awkward to remain involved knowing that a legal threat was in the air.
Hospice met with Dennis and Alice. They mercifully stepped in and provided their healing palliative care. Although plans were made to have hospice at home, Alice balked. After a few weeks Dennis died peacefully in a hospital hospice unit.
Comment: As I think about Dennis and Alice, I wonder what I could have done better in communication. I'm not sure. I did find out that Alice tried to find a plaintiff's attorney to file suit. They had several experts review the records, but they all advised her that she had no reasonable grounds to forge ahead legally with her complaints. I felt Dennis' care had been good and wasn't very concerned, but was reminded that it often takes several things to bring about a medical malpractice claim: a poor outcome, communication breakdown, anger, and a mistake or oversight of consequence. Our tort system is cumbersome and expensive. It's not the major factor driving medical costs these days, but is significant and will need reform. But can we ever get there?
Dennis was a well liked family doctor. About five years earlier a "coin lesion" was discovered on a chest X-Ray. This 2cm spot in the right upper lobe had a smooth rounded border and didn't contain calcium. A CT scan showed no enlarged lymph nodes and no other spots elsewhere. A needle biopsy of the spot was not diagnostic. We knew the spot was new because an X-Ray five years earlier was normal. He hadn't traveled to an area where Valley Fever or other fungal infections were common.
At surgery, the right upper lobe was removed along with local lymph nodes. The lesion turned out to be a primary lung sarcoma, a quite unusual type of lung cancer. One of the lymph nodes was positive. We sent Dennis to local experts on sarcoma and several opinions from cancer specialists were obtained. The consensus at that time was that sarcomas don't respond very well to either chemo or radiation therapy, but after further opinions, Dennis had a series of radiation treatments.
After that it was waiting. For three years, there was little change. Then fluid began to accumulate in the right lung cavity and some density in the area of radiation (often radiation changes). I drained the fluid from Dennis' chest several times. No cancer cells were found. After more signs of progression but no proof of recurrence, I sent Dennis to the top academic chest surgeon in the area who admitted Dennis to the hospital. After more conferencing there, he attempted a complete removal of the right lung in order to try to remove all the residual tumor. Dennis had a very stormy post-op course and required ICU care and a ventilator for almost three months before being successfully weaned off. However, the sarcoma was never completely removed, thus still progressing.
He was then transferred back to my hospital where I met with Alice. Somehow I was the focus of her anger about her husbands tragic illness, and extensive suffering especially over the past year with heroic attempts to deal with the recurring sarcoma. We had social service and others involved. To say the least it was awkward to remain involved knowing that a legal threat was in the air.
Hospice met with Dennis and Alice. They mercifully stepped in and provided their healing palliative care. Although plans were made to have hospice at home, Alice balked. After a few weeks Dennis died peacefully in a hospital hospice unit.
Comment: As I think about Dennis and Alice, I wonder what I could have done better in communication. I'm not sure. I did find out that Alice tried to find a plaintiff's attorney to file suit. They had several experts review the records, but they all advised her that she had no reasonable grounds to forge ahead legally with her complaints. I felt Dennis' care had been good and wasn't very concerned, but was reminded that it often takes several things to bring about a medical malpractice claim: a poor outcome, communication breakdown, anger, and a mistake or oversight of consequence. Our tort system is cumbersome and expensive. It's not the major factor driving medical costs these days, but is significant and will need reform. But can we ever get there?
Saturday, April 7, 2012
Health Care Costs - the Leaky Bucket
Recently I was sent this commentary on the issue of health care costs. It seemed like a pretty good summary of the problem to me, though it didn't delve into solutions or the current controversy about the Affordable Health Care Act. In our country, we've built up a huge medical-industrial system that can do lots of good but at a huge cost. It seems that we are on the brink of a "health care-cost bubble" because we are now dragging down economic growth with continued double digit rising insurance rates. Individuals, small businesses, corporations, and government entities are all crying for relief from this health care cost burden. An example of the medical-industrial complex is in the area of sleep apnea treatment.
A splashy story about a successful company in San Diego, ResMed, was published in the Union Tribune recently. Not much was said about their medical devices but their CEO has "spent $10 million so far for art in the company's 18 locations around the world". Apparently it's felt that these millions spent for art help to inspire the workers. This is a small example of the extraordinary spending in the medical-industrial complex. Multiple profitable health care businesses are benefiting from the "piggy-bank" bulging with growing health care dollars. Many MD's in top administrative positions in non-profit hospitals make more than one million dollars. Now, I understand that most of the drug companies, device makers, glass and steel hospitals, procedure doctors, medical directors, CEO's, scanners, robotic devices, etc. are wonderful, but just not wonderful in their current excesses. The challenge is to change incentives in order to bring costs down.
There are a number of possibilities for improvement, and one of the smartest of the innovators is Dr. Donald Berwick. This Harvard Pediatrician recently had to step down after about a year and a half as the head of the Center for Medicare and Medicaid Services. He was a recess appointee by President Obama and had no chance for a permanent appointment by the US Congress. Kaiser Health News recently noted the top five accomplishments at CMS by Dr. Berwick. His leaving is certainly a set-back to accelerating reform, however he remains a nationally respected promoter of quality improvement.
The Hastings Center, a non-profit which deals with ethical issues, has published a Health Care Costs Monitor containing several articles with different takes on the issue. One by ethicist Daniel Callahan deals with the cost of end-of-life care, a problem in every ICU in every hospital in the USA.
Recently the New Yorker reported that, "Yet, strange as it may sound, the federal government does not have a spending problem per se. What it has is a health-care problem. The cost of most budget items typically rises at a reasonable rate, if at all, but the cost of Medicare, Medicaid, and the tax subsidy for employer-provided insurance has been rising much faster than everything else..."
Dr. Berwick has shown that there's good evidence that we can still maintain and improve quality while trimming costs. But do we have the political will? Every dollar spent is "benefiting" someone. In the equation are the patient, doctor, administrator, nurse, other providers, clinics, hospitals, device manufacturers, drug companies, lobbyists, research tanks, politicians, pharmacies, nursing homes, unions, AARP, insurance companies, Wall Street, etc.
Some doctors and medical specialty societies are addressing the problem of overuse of technology. These physicians look at the research evidence and encourage limiting unnecessary testing and treatment. Although this isn't rocket science, it is quite hard to implement change in both lucrative medical procedures and the desire by some patients to "do everything."
It seems like a huge bucket of largely poorly controlled health dollars is being sprinkled around with often ineffective and wasteful administrative attempts at control. Let's hope we find ways to get a much less leaky bucket soon. Our medical-industrial system is long overdue for a real wake-up and shakeup. Here's an example from an interview with Stanford economist Victor Fuchs.
A splashy story about a successful company in San Diego, ResMed, was published in the Union Tribune recently. Not much was said about their medical devices but their CEO has "spent $10 million so far for art in the company's 18 locations around the world". Apparently it's felt that these millions spent for art help to inspire the workers. This is a small example of the extraordinary spending in the medical-industrial complex. Multiple profitable health care businesses are benefiting from the "piggy-bank" bulging with growing health care dollars. Many MD's in top administrative positions in non-profit hospitals make more than one million dollars. Now, I understand that most of the drug companies, device makers, glass and steel hospitals, procedure doctors, medical directors, CEO's, scanners, robotic devices, etc. are wonderful, but just not wonderful in their current excesses. The challenge is to change incentives in order to bring costs down.
There are a number of possibilities for improvement, and one of the smartest of the innovators is Dr. Donald Berwick. This Harvard Pediatrician recently had to step down after about a year and a half as the head of the Center for Medicare and Medicaid Services. He was a recess appointee by President Obama and had no chance for a permanent appointment by the US Congress. Kaiser Health News recently noted the top five accomplishments at CMS by Dr. Berwick. His leaving is certainly a set-back to accelerating reform, however he remains a nationally respected promoter of quality improvement.
The Hastings Center, a non-profit which deals with ethical issues, has published a Health Care Costs Monitor containing several articles with different takes on the issue. One by ethicist Daniel Callahan deals with the cost of end-of-life care, a problem in every ICU in every hospital in the USA.
Recently the New Yorker reported that, "Yet, strange as it may sound, the federal government does not have a spending problem per se. What it has is a health-care problem. The cost of most budget items typically rises at a reasonable rate, if at all, but the cost of Medicare, Medicaid, and the tax subsidy for employer-provided insurance has been rising much faster than everything else..."
Dr. Berwick has shown that there's good evidence that we can still maintain and improve quality while trimming costs. But do we have the political will? Every dollar spent is "benefiting" someone. In the equation are the patient, doctor, administrator, nurse, other providers, clinics, hospitals, device manufacturers, drug companies, lobbyists, research tanks, politicians, pharmacies, nursing homes, unions, AARP, insurance companies, Wall Street, etc.
Some doctors and medical specialty societies are addressing the problem of overuse of technology. These physicians look at the research evidence and encourage limiting unnecessary testing and treatment. Although this isn't rocket science, it is quite hard to implement change in both lucrative medical procedures and the desire by some patients to "do everything."
It seems like a huge bucket of largely poorly controlled health dollars is being sprinkled around with often ineffective and wasteful administrative attempts at control. Let's hope we find ways to get a much less leaky bucket soon. Our medical-industrial system is long overdue for a real wake-up and shakeup. Here's an example from an interview with Stanford economist Victor Fuchs.
Monday, April 2, 2012
Leaving a Legacy
Have you ever thought about what you want to leave behind. I'm not really referring to estate planning or legal documents. I'd like us to think about a legacy of values and ideas, something that is uniquely you that you'd like others to know about. Perhaps you could be an influence on another life as yours may be ending. In the past, oral tradition played the major role, then written letters, now it's digital media.
A non-profit called StoryCorps is doing a very nice job of bridging the generational divide by providing the opporunity of record, share, and preserve stories of our lives. A currently featured story is a conversation between a son and father, as the latter is facing metastatic incurable cancer.
Another way of communicating is to prepare an Ethical Will. This can both be a spiritual or moral legacy as well as a way of stating your values. This document can be incorporated into your advance directives for end of life decision making.
StoryCorps reminds us that very important conversations not only need to take place, but that recording them provides a special way to link to present and future generations.
A non-profit called StoryCorps is doing a very nice job of bridging the generational divide by providing the opporunity of record, share, and preserve stories of our lives. A currently featured story is a conversation between a son and father, as the latter is facing metastatic incurable cancer.
Another way of communicating is to prepare an Ethical Will. This can both be a spiritual or moral legacy as well as a way of stating your values. This document can be incorporated into your advance directives for end of life decision making.
StoryCorps reminds us that very important conversations not only need to take place, but that recording them provides a special way to link to present and future generations.
Monday, March 12, 2012
Advancing Care with the POLST Form
Coming soon, on April 16th, is National Health Care Decisions Day. Hoperfully this will be a reminder to medical care organizations to further reach out to their communities in order to provide education and access to advance care directives. The documents that attorneys provide and that are available on-line are the Living Will and Durable Power of Attorney for Health Care. These are also available from many state medical associations and other community service groups. A few communities such as La Crosse, Wisconsin have been very successful in promoting community wide use of advance directives.
There are now excellent resources for individuals, community groups, and states to further develop programs in advance care planning. A recent conference was held in San Diego, California. The remarkable efforts in California and the national progress pioneered in Oregon are now available. The "state of the art" in developing POLST (Physician Orders for Life Sustaining Treatment) programs can be found by visiting these two links.
The advancement in the development of POLST programs across the country is impressive. However, to enhance the effectiveness, more funding is needed for registries to be available 24/7 and more grants are needed for quality and outcome research. Progress has been made, but there's much more still to be done.
There are now excellent resources for individuals, community groups, and states to further develop programs in advance care planning. A recent conference was held in San Diego, California. The remarkable efforts in California and the national progress pioneered in Oregon are now available. The "state of the art" in developing POLST (Physician Orders for Life Sustaining Treatment) programs can be found by visiting these two links.
The advancement in the development of POLST programs across the country is impressive. However, to enhance the effectiveness, more funding is needed for registries to be available 24/7 and more grants are needed for quality and outcome research. Progress has been made, but there's much more still to be done.
Friday, March 9, 2012
The Lake Woebegon Effect
There are two very interesting books out about how we, as doctors and patients, approach health care. One, How Doctor's Think gives us insight as to how doctors tend to approach the care of patients. The other, Your Medical Mind , also by Jerome Groopman with Pamela Hartzband, helps us as patients understand the complexities of medical decision making.
One perplexing dilemma I noted over the years in the ICU was the tendency of families to be unrealistically (from my perspective) optimistic about the survival chances of their loved ones. When I'd discuss a probability of a 5% chance of survival, or even less than 1%, in a direly ill patient on a ventilator with multiple organs failing, a family member might understand the poor chances, yet believe that they could beat the odds - much I suppose like the Las Vegas gambler except the stakes were so much higher in the ICU.
Educators are familiar with the Lake Woebegon Effect, in that when surveyed almost all feel that their students are above average. When it comes to health care in the ICU a recent study confirmed that families tend to have an optimistic bias. This, of course, seems natural when you think about it. Not wanting to lose a loved one, we martial all the resources to keep them alive - including an optimistic bias about the facts presented to us. To me this at least in part explains the very difficult process of shifting from full bore heroic ICU care toward palliative symptom control.
Part of it may be a doctor's reluctance to use such words as, "Your wife is dying and we are doing everything possible to make her comfortable, but I don't recommend attempts to attempt CPR or heart shocks which may cause pain and which would be ineffective."
The more we can understand the psychology of medical decision making, the better we will be at end of life care. It is the intersection of philosophy, religion, emotions - and life itself. The complexities of the interactions can be dramatic or mundane - but very human as doctors and patients try to work through the Lake Woebegon Effect.
One perplexing dilemma I noted over the years in the ICU was the tendency of families to be unrealistically (from my perspective) optimistic about the survival chances of their loved ones. When I'd discuss a probability of a 5% chance of survival, or even less than 1%, in a direly ill patient on a ventilator with multiple organs failing, a family member might understand the poor chances, yet believe that they could beat the odds - much I suppose like the Las Vegas gambler except the stakes were so much higher in the ICU.
Educators are familiar with the Lake Woebegon Effect, in that when surveyed almost all feel that their students are above average. When it comes to health care in the ICU a recent study confirmed that families tend to have an optimistic bias. This, of course, seems natural when you think about it. Not wanting to lose a loved one, we martial all the resources to keep them alive - including an optimistic bias about the facts presented to us. To me this at least in part explains the very difficult process of shifting from full bore heroic ICU care toward palliative symptom control.
Part of it may be a doctor's reluctance to use such words as, "Your wife is dying and we are doing everything possible to make her comfortable, but I don't recommend attempts to attempt CPR or heart shocks which may cause pain and which would be ineffective."
The more we can understand the psychology of medical decision making, the better we will be at end of life care. It is the intersection of philosophy, religion, emotions - and life itself. The complexities of the interactions can be dramatic or mundane - but very human as doctors and patients try to work through the Lake Woebegon Effect.
Thursday, March 8, 2012
Excessive Use of "Health Care"
Ask almost any doctor or nurse, and they can tell stories about mess-ups in health care. Sometimes, it's under utilization, sometimes the wrong treatment or test is done, and sometimes it's inappropriate overuse of tests or treatments.
I was discussing this with an ophthalmologist recently. He had been working for a large medical group with a business office concerned about high overhead costs and the "inadequate" revenue from the expensive equipment. The 11 ophthalmologists were told directly by a VP administrator that they weren't billing enough and thus they weren't meeting their targeted revenues. They doctors countered that they were providing appropriate and high quality care for their patients. The administrator countered, "Listen, if you have a patient in the office and there's a billable procedure, DO IT"!
Six of the doctors rebelled and subsequently left this group, after making their position clear that they wanted to practice within both legal and ethical boundaries - and could no longer do so in the cost/procedure driven environment.
When I was scouting around for my first job in internal medicine, a group of doctors asked me if I was interested in becoming their "thyroid guy". They had just purchased a thyroid scanner and felt they had a golden opportunity to generate a high revenue stream from Medicare and insurance billing. They were also doing routine viral cultures on sore throats (not at all worthwhile) to generate revenue. I didn't say it directly to them, but why did they exploit the potential to overuse diagnostic procedures? Did they derail their idealism somewhere in training?
Amazingly there is very little documentation about unnecessary testing and treatment. Recently the Archives of Internal Medicine reported a study in which the authors researched the entirety of 21 years of medical literature evaluating 114,831 publications. They found only 172 articles with data on health care overuse—and most were devoted to either overusing antibiotics for upper respiratory infections, or three cardiovascular procedures.
It is estimated that 30% of health care costs are unnecessary, but how do we arrive at reliable information about overuse? Even more difficult, how do we change behaviors? All of us have ideas such as changing incentives, tort reform, more evidence based research, expert opinion guidelines, more primary care teams, etc. Unfortunately the current proposals for health care reform don't effectively attempt to deal with overuse of scarce and expensive resources. But the end of double digit health care cost escalation will come, like it or not. Let's hope the public discourse can be rational, not "don't let the government mess with my Medicare!"
It's quite likely that end-of-life care is unnecessarily costly, both in suffering and dollars. There is wide variation in hospice use and dying in the hospital from city to city. Such wide variation demonstrates how much improvement in care is possible.
PS: Having my own health coverage under Medicare now, I do appreciate this nationwide (gasp) socialized medicine. It is too costly at present, but if we can be successful in dealing with overuse, this will correct dramatically.
I was discussing this with an ophthalmologist recently. He had been working for a large medical group with a business office concerned about high overhead costs and the "inadequate" revenue from the expensive equipment. The 11 ophthalmologists were told directly by a VP administrator that they weren't billing enough and thus they weren't meeting their targeted revenues. They doctors countered that they were providing appropriate and high quality care for their patients. The administrator countered, "Listen, if you have a patient in the office and there's a billable procedure, DO IT"!
Six of the doctors rebelled and subsequently left this group, after making their position clear that they wanted to practice within both legal and ethical boundaries - and could no longer do so in the cost/procedure driven environment.
When I was scouting around for my first job in internal medicine, a group of doctors asked me if I was interested in becoming their "thyroid guy". They had just purchased a thyroid scanner and felt they had a golden opportunity to generate a high revenue stream from Medicare and insurance billing. They were also doing routine viral cultures on sore throats (not at all worthwhile) to generate revenue. I didn't say it directly to them, but why did they exploit the potential to overuse diagnostic procedures? Did they derail their idealism somewhere in training?
Amazingly there is very little documentation about unnecessary testing and treatment. Recently the Archives of Internal Medicine reported a study in which the authors researched the entirety of 21 years of medical literature evaluating 114,831 publications. They found only 172 articles with data on health care overuse—and most were devoted to either overusing antibiotics for upper respiratory infections, or three cardiovascular procedures.
It is estimated that 30% of health care costs are unnecessary, but how do we arrive at reliable information about overuse? Even more difficult, how do we change behaviors? All of us have ideas such as changing incentives, tort reform, more evidence based research, expert opinion guidelines, more primary care teams, etc. Unfortunately the current proposals for health care reform don't effectively attempt to deal with overuse of scarce and expensive resources. But the end of double digit health care cost escalation will come, like it or not. Let's hope the public discourse can be rational, not "don't let the government mess with my Medicare!"
It's quite likely that end-of-life care is unnecessarily costly, both in suffering and dollars. There is wide variation in hospice use and dying in the hospital from city to city. Such wide variation demonstrates how much improvement in care is possible.
PS: Having my own health coverage under Medicare now, I do appreciate this nationwide (gasp) socialized medicine. It is too costly at present, but if we can be successful in dealing with overuse, this will correct dramatically.
Friday, February 17, 2012
Is it Time for Marge to do a POLST?
Marge was aging and gradually "falling apart", as she would say. "First it was my back, then my knees, and now my heart is giving out". She confronted her doctor with this in a frustrated manner, "I'm no good for anything anymore. I can't really enjoy the things I used to. Most of my friends have died off, so maybe I'm next".
The doctor in sizing up Marge's advanced age and frailties reviewed her Living Will and Durable Power of Attorney for Health Care. These documents were correctly completed and signed, but what level of care would Marge really want? Her Living Will said she would not want CPR if her heart stopped and doctors felt she was terminally ill, but that wouldn't really stop Medics summoned by 911 from doing everything until more information could be obtained.
Her doctor explained, "Marge, the documents don't really tell me whether you would want antibiotics for a pneumonia, whether you would want to exit this world at home or in the hospital, or whether you'd want tube feeding if you are mentally incapacitated. We need to talk about a POLST form to really document what you value!"
"What's a POLST form"?
"Well, it stands for Physician's Orders for Life Sustaining Treatment. It gets what you want down in black and white. It will be honored everywhere in the state and get you the care you've requested."
Marge was a little puzzled, "How does it work?"
They spent the next 10 minutes completing Marge's POLST. Fortunately her daughter was present for the conversation. Marge confirmed she did not want CPR under any circumstances. The second and really more important part of the form dealt with the level of care she would want. She still valued life and would want to go to the hospital if that helped, have antibiotics, and even artificial fluids and nutrition. But there were limits, "Doctor, if I have a stroke or dementia or am otherwise not with it, then I'd want comfort measures only."
Marge took this co-signed document home after leaving a copy at the doctor's office. It was to be submitted by the doctor to a registry. At home it was placed on the refrigerator and copies given to close family members. All in all, Marge felt that she was now in more control of her own destiny.
Comment: I attended the National POLST conference in San Diego recently and was most impressed at the leadership of Oregon State in disseminating expertise to other states. There are communication, legal, legislative, and medical issues unique to each state. Now a majority of the states have programs in place. The registry created in Oregon is allowing research for the first time on the effectiveness of the POLST document and helping direct quality improvement efforts. The research letter recently published in JAMA by Dr. Susan Tolle's group is showing the way toward the future. Since CPR is generally ineffective in patients with advanced illness, the question about CPR isn't the most important one. More importantly the patient's wishes about quality of life and level of care need to be explored and documented. The POLST document is most appropriate for those in the last year of their life or for the very frail elderly when their wishes and values are clear. Having the POLST conversation is something we all need to learn and do well.
The doctor in sizing up Marge's advanced age and frailties reviewed her Living Will and Durable Power of Attorney for Health Care. These documents were correctly completed and signed, but what level of care would Marge really want? Her Living Will said she would not want CPR if her heart stopped and doctors felt she was terminally ill, but that wouldn't really stop Medics summoned by 911 from doing everything until more information could be obtained.
Her doctor explained, "Marge, the documents don't really tell me whether you would want antibiotics for a pneumonia, whether you would want to exit this world at home or in the hospital, or whether you'd want tube feeding if you are mentally incapacitated. We need to talk about a POLST form to really document what you value!"
"What's a POLST form"?
"Well, it stands for Physician's Orders for Life Sustaining Treatment. It gets what you want down in black and white. It will be honored everywhere in the state and get you the care you've requested."
Marge was a little puzzled, "How does it work?"
They spent the next 10 minutes completing Marge's POLST. Fortunately her daughter was present for the conversation. Marge confirmed she did not want CPR under any circumstances. The second and really more important part of the form dealt with the level of care she would want. She still valued life and would want to go to the hospital if that helped, have antibiotics, and even artificial fluids and nutrition. But there were limits, "Doctor, if I have a stroke or dementia or am otherwise not with it, then I'd want comfort measures only."
Marge took this co-signed document home after leaving a copy at the doctor's office. It was to be submitted by the doctor to a registry. At home it was placed on the refrigerator and copies given to close family members. All in all, Marge felt that she was now in more control of her own destiny.
Comment: I attended the National POLST conference in San Diego recently and was most impressed at the leadership of Oregon State in disseminating expertise to other states. There are communication, legal, legislative, and medical issues unique to each state. Now a majority of the states have programs in place. The registry created in Oregon is allowing research for the first time on the effectiveness of the POLST document and helping direct quality improvement efforts. The research letter recently published in JAMA by Dr. Susan Tolle's group is showing the way toward the future. Since CPR is generally ineffective in patients with advanced illness, the question about CPR isn't the most important one. More importantly the patient's wishes about quality of life and level of care need to be explored and documented. The POLST document is most appropriate for those in the last year of their life or for the very frail elderly when their wishes and values are clear. Having the POLST conversation is something we all need to learn and do well.
Saturday, January 28, 2012
I'm a Happy Electronic Patient
I was nervous as electronic records were being rolled out at Group Health Co-op in Puget Sound. I already had a "consumer number" and was wondering how depersonalized this was going to get.
Then I went on-line and joined MyGroupHealth which gave me my own secure web page. There was only a bit of a learning curve as I went to the computer to make an appointment with my GP. I was surprised to find his on-line schedule available and open at a time I wanted, so with a click I booked myself for that time slot - no scheduler, red tape, or call backs. I got a secure email reminder before the appointment asking me to fill out my history on line. Reminders were flagged that I hadn't had a tetanus shot in more than 10 years and I was due for lipid screening and colon cancer screening.
I learned that my medications could be refilled by checking a box on-line and they would be mailed to my home. The lab tests were posted and available for review as were all prior tests, X-Rays, and procedures. There's even an iPod app available for pharmacy and lab wait times as well as checking my medical record on the go.
One weekend I had a flare of my sinus disease with a 102 fever. A consulting nurse, available 24/7, reviewed my records as I talked with her by phone, and it was apparent which antibiotic seemed most appropriate to start without delay.
Then I lost one of the lenses in my glasses. Fortunately the recent results of my eye exam were available on-line so there was no delay in getting a replacement at Costco (we were out of town).
When going in for surgery, there was a complete record of my allergies, meds, prior surgeries, etc. There were no lost charts and no confusion about my case.
Also, on-line I can research the management of any illnesses I might have on the secure web site. This information has been vetted, thus more useful than scouring the many internet sites. Also, I can look at my life style risk factors and see where I need to focus on diet and exercise.
So I don't find this at all depersonalized. It puts me in the driver's seat and helps the docs focus on the sicker patients. Since they are salaried without the requirement for "face-time", they conduct many "virtual visits" in a very cost-effective way.
My advance directives including a Living Will, Values Statement and Durable Power of Attorney for Health Care are also stored in my electronic data base at Group Health and are available 24/7. So if and when there's a crisis I have a good chance that these important documents will be readily available.
Hopefully, medicine will continue to evolve using all the benefits of the electronic record. As an "electronic patient" I'm certainly a fan.
Then I went on-line and joined MyGroupHealth which gave me my own secure web page. There was only a bit of a learning curve as I went to the computer to make an appointment with my GP. I was surprised to find his on-line schedule available and open at a time I wanted, so with a click I booked myself for that time slot - no scheduler, red tape, or call backs. I got a secure email reminder before the appointment asking me to fill out my history on line. Reminders were flagged that I hadn't had a tetanus shot in more than 10 years and I was due for lipid screening and colon cancer screening.
I learned that my medications could be refilled by checking a box on-line and they would be mailed to my home. The lab tests were posted and available for review as were all prior tests, X-Rays, and procedures. There's even an iPod app available for pharmacy and lab wait times as well as checking my medical record on the go.
One weekend I had a flare of my sinus disease with a 102 fever. A consulting nurse, available 24/7, reviewed my records as I talked with her by phone, and it was apparent which antibiotic seemed most appropriate to start without delay.
Then I lost one of the lenses in my glasses. Fortunately the recent results of my eye exam were available on-line so there was no delay in getting a replacement at Costco (we were out of town).
When going in for surgery, there was a complete record of my allergies, meds, prior surgeries, etc. There were no lost charts and no confusion about my case.
Also, on-line I can research the management of any illnesses I might have on the secure web site. This information has been vetted, thus more useful than scouring the many internet sites. Also, I can look at my life style risk factors and see where I need to focus on diet and exercise.
So I don't find this at all depersonalized. It puts me in the driver's seat and helps the docs focus on the sicker patients. Since they are salaried without the requirement for "face-time", they conduct many "virtual visits" in a very cost-effective way.
My advance directives including a Living Will, Values Statement and Durable Power of Attorney for Health Care are also stored in my electronic data base at Group Health and are available 24/7. So if and when there's a crisis I have a good chance that these important documents will be readily available.
Hopefully, medicine will continue to evolve using all the benefits of the electronic record. As an "electronic patient" I'm certainly a fan.
Saturday, December 24, 2011
A Lethal Injection
I entered the exam room as an intravenous catheter was being inserted expertly. The procedure had been explained to me. I wanted to be there to comfort my friend in his last moments. Life had been getting difficult and the infirmities and pain too severe. The doctor entered the room with an appropriate look of sympathy on his face and reviewed the case agreeing that my friend's quality of life was severely impaired.
The sodium pentothal was slowly injected IV. I saw a questioning look on my friend's face, he then slumped to the table and died. Being unconscious, his breathing almost immediately stopped, then the heart beat ceased a few minutes later. It seemed so fast.
I loved my friend, my companion, my dog. We walked in the park or on the beach every morning. He greeted me, my wife, my children, and my grandchildren each day like long lost friends. His goal in the yard (thus in life) was to be protective seemingly at all costs.
Today we grieve, but not like when I lost my mother or father, or when I lost a patient. It's a mixture of sadness for our loss, but contentment that he didn't suffer and could have a peaceful end.
Many patients over the years asked me for a peaceful painless end. Before hospice and palliative care, a patient would often sense abandonment or a loss of control at the end saying, "Doctor, my dog was treated more humanely at the end than my father was." Ironically, my experience today has brought me to question how humane we humans really are in our treatment of each other at the end. Do we have lessons to learn?
The sodium pentothal was slowly injected IV. I saw a questioning look on my friend's face, he then slumped to the table and died. Being unconscious, his breathing almost immediately stopped, then the heart beat ceased a few minutes later. It seemed so fast.
I loved my friend, my companion, my dog. We walked in the park or on the beach every morning. He greeted me, my wife, my children, and my grandchildren each day like long lost friends. His goal in the yard (thus in life) was to be protective seemingly at all costs.
Today we grieve, but not like when I lost my mother or father, or when I lost a patient. It's a mixture of sadness for our loss, but contentment that he didn't suffer and could have a peaceful end.
Many patients over the years asked me for a peaceful painless end. Before hospice and palliative care, a patient would often sense abandonment or a loss of control at the end saying, "Doctor, my dog was treated more humanely at the end than my father was." Ironically, my experience today has brought me to question how humane we humans really are in our treatment of each other at the end. Do we have lessons to learn?
Tuesday, December 13, 2011
Making Our Values Known
One day in my office, an elderly couple said that they had a document they wanted to add to their advance directive. It went as follows:
"I have a firm belief that God created me, that there is a natural cycle of life, that death is inevitable, and that dying should be peaceful, comfortable, at home, if possible, and without tubes, artificial nutrition and ventilator support. If I cannot carry out self care, do not have my usual mental faculties, or have an incurable disease or intractable pain, please treat me with the best care for comfort but not invasive life support care. It is quite acceptable to withhold fluid and nutrition from me and treat me with a morphine drip as part of this care for comfort, letting nature take its course. I have no wish to be a burden to my loved ones, or to spend resources and energy on heroic efforts to prolong my life when life is at end. Only in the acute situation (e.g. trauma) would I want heroic life support to try to get me back to my present state of good health. My worst nightmare is to spend my days in a nursing home with a feeding tube. Quality, not quantity,of earthly life is more important". I was delighted that they had taken the initiative and that we could talk things over.
This type of statement can be added to one's living will and serves as a very important guide to the physician and your loved ones. The conversation is focused on your values, not just on what high tech marginally beneficial treatment could be attempted. Please consider doing this or something similar such as a Five Wishes form or one from Compassion and Choices. Also, general values statements can be of use.
The ultimate document putting values into medical orders is the POLST form, but this form is generally most applicable in the last year of life, for hospice patients, or for the frail elderly who are sure what they would or wouldn't want in a medical crisis. For the rest of us, the addition of a values statement to our living will (plus having the important discussions with our family, friends, physicians, and durable power of attorney for health care) will be our best assurance that indeed our wishes will be respected.
"I have a firm belief that God created me, that there is a natural cycle of life, that death is inevitable, and that dying should be peaceful, comfortable, at home, if possible, and without tubes, artificial nutrition and ventilator support. If I cannot carry out self care, do not have my usual mental faculties, or have an incurable disease or intractable pain, please treat me with the best care for comfort but not invasive life support care. It is quite acceptable to withhold fluid and nutrition from me and treat me with a morphine drip as part of this care for comfort, letting nature take its course. I have no wish to be a burden to my loved ones, or to spend resources and energy on heroic efforts to prolong my life when life is at end. Only in the acute situation (e.g. trauma) would I want heroic life support to try to get me back to my present state of good health. My worst nightmare is to spend my days in a nursing home with a feeding tube. Quality, not quantity,of earthly life is more important". I was delighted that they had taken the initiative and that we could talk things over.
This type of statement can be added to one's living will and serves as a very important guide to the physician and your loved ones. The conversation is focused on your values, not just on what high tech marginally beneficial treatment could be attempted. Please consider doing this or something similar such as a Five Wishes form or one from Compassion and Choices. Also, general values statements can be of use.
The ultimate document putting values into medical orders is the POLST form, but this form is generally most applicable in the last year of life, for hospice patients, or for the frail elderly who are sure what they would or wouldn't want in a medical crisis. For the rest of us, the addition of a values statement to our living will (plus having the important discussions with our family, friends, physicians, and durable power of attorney for health care) will be our best assurance that indeed our wishes will be respected.
Saturday, December 10, 2011
Saying Goodbye - The Descendants
The young woman lays dying suffering severe brain trauma from a boating accident. Her husband and two daughters are devastated each in a very different way. Friends try to help and also need to say goodbye. The advance directive is clear and there is no conflict that her wishes need to be carried out. A date for removal of the ventilator is set, and all come to say goodbye is their own way. Grief is mixed with anger, blame, love, confusion, and a need to control.
This story doesn't sound like Hollywood, yet this end-of-life story was surprisingly released in this pre-Christmas season. George Clooney's leading role in The Descendants plus the film's gorgeous setting in Hawaii should help draw folks to the box office even though some critics find the story depressing - a mixture of humor and sadness.
The thing that strikes me about this very well done movie is that it's really not about the end of a life. It's about how we grieve and become more real as we finally face emotions as they surface, as we assimilate new facts and as we deal with old unresolved conflicts. Can we be angry at the dying person or each other? You bet. Can teens act at their worst? Of course. Can we make more ethical decisions about how to live our lives? Maybe.
So if you want to laugh, cry, grieve, and have hope for our humanness, go see The Decendants!
This story doesn't sound like Hollywood, yet this end-of-life story was surprisingly released in this pre-Christmas season. George Clooney's leading role in The Descendants plus the film's gorgeous setting in Hawaii should help draw folks to the box office even though some critics find the story depressing - a mixture of humor and sadness.
The thing that strikes me about this very well done movie is that it's really not about the end of a life. It's about how we grieve and become more real as we finally face emotions as they surface, as we assimilate new facts and as we deal with old unresolved conflicts. Can we be angry at the dying person or each other? You bet. Can teens act at their worst? Of course. Can we make more ethical decisions about how to live our lives? Maybe.
So if you want to laugh, cry, grieve, and have hope for our humanness, go see The Decendants!
Saturday, November 19, 2011
Is it Time for Hospice?
I was on the phone last night with a physician colleague. George (not his real name) had, as his first symptom, excruciating pain in the mid back and left shoulder. The pain was so severe that he ranked it a 10 out of 10. It didn't take long to diagnose the problem - pancreatic cancer which had invaded the diaphragm and spread to the lungs. This was only three weeks ago. Just prior to that he'd been well, hiking and river rafting - two of his favorite things to do in retirement. After seeing Oncology, chemotherapy was initiated mostly to try to control the pain.
Without George being able to attend, a small group of us gathered last night to give both phone and written messages to him. It was sad yet uplifting. All were worried though that George's pain wasn't really well controlled. When I got on the phone with him, his voice sounded strong, "the problem is that I didn't tolerate chemo, the pain is still there and I'm not sleeping well. I'm not afraid of death, but I just don't want to be there when it happens (saying that this was one of his favorite quotes from Woody Allen)."
I said, "George have you thought about hospice? I know this has been so quick but they can make your days so much more comfortable."
George was ahead of me, "I'm calling them tomorrow. Also, I've checked out the Washington State End of Life Coalition. They have excellent resources for someone like me including information about palliative care, hospice and the POLST form. I'll need to work with my doctor on that."
What else was left for me to say? I told him that we were all thinking of him and of the great times we had traveling together. Basically it ended with, "God bless, we're keeping you in our prayers." I don't know what really helps, but it helped me and my wife to at least try to reach out.
Without George being able to attend, a small group of us gathered last night to give both phone and written messages to him. It was sad yet uplifting. All were worried though that George's pain wasn't really well controlled. When I got on the phone with him, his voice sounded strong, "the problem is that I didn't tolerate chemo, the pain is still there and I'm not sleeping well. I'm not afraid of death, but I just don't want to be there when it happens (saying that this was one of his favorite quotes from Woody Allen)."
I said, "George have you thought about hospice? I know this has been so quick but they can make your days so much more comfortable."
George was ahead of me, "I'm calling them tomorrow. Also, I've checked out the Washington State End of Life Coalition. They have excellent resources for someone like me including information about palliative care, hospice and the POLST form. I'll need to work with my doctor on that."
What else was left for me to say? I told him that we were all thinking of him and of the great times we had traveling together. Basically it ended with, "God bless, we're keeping you in our prayers." I don't know what really helps, but it helped me and my wife to at least try to reach out.
Sunday, October 23, 2011
A Note From Israel
Below is a commentary that I have permission to pass on from Dr. Leibovich. It points out to me that the issue of forcing the dying patient into the hospital may be an international problem, especially in the more developed countries.
"Today I found your blog on End of Life issues. I spent several hours reading all your posts, and I wanted to thank you for writing.
I want to apologize for my basic English, but I hope you'll understand. I wish I could write like you do…
I am a family physician in a Kibbutz in Israel and I take care of almost all the people in the Kibbutz, from birth to death. I am faced with end of life issues quite often, and I feel that I have the exact same views on this like you. I am fortunate to be able to help many patients and families to avoid futile hospital care, and this is one of the things I am very proud of.
A few months ago I took care of my stepfather who lived in a fancy place for old people who can take care of themselves and live alone in a nice flat, but they have a restaurant, have cultural activities etc, in a big city. (I don't know what this kind of place is called in English – here it's called something like "sheltered living"). At the age of 89 he started getting weaker and needed more and more help with his daily activities, until finally he needed constant care. Cancer was diagnosed. We got someone to take care of him 24 hours a day. When he got to the stage where he needed a wheelchair the management of this place did whatever they could to get him to leave – to a nursing home (with four people in a hospital bed in a room), a hospital or whatever. He had already sold his previous home, and he expected to live in this place for the rest of his life. He was alert and understood they wanted to get rid of him, as this spoiled their nice place for "the young at heart". They referred me to the contract where it says that this is a place for independent people. I managed to take care of him in his flat and refused to take him to the hospital, as this was his explicit wish, and we all knew that there was nothing they could do better in the hospital than we could do in his own home and bed. In the last week of his life I was there most of the time, gave him medications against pain, and he passed away in his bed surrounded by those who loved him. I was very happy to have been able to do this for him. I was very sad that this had to be done fighting the management all the way. They threatened me that I was denying him adequate care in a hospital, where he should be in his situation. I ignored them as I knew his time was getting short, and I didn't believe they would try to evacuate him forcefully in his situation. He passed away a day before another meeting they set up to tell me I had to take him somewhere else.
So I am glad to read your stories that show me that I am not alone in the thought that if there is nothing more medicine can do the best place for a person to finish his life is in his own home, if this is what he wants.
All the best, Mira Leibovich, MD - Israel"
"Today I found your blog on End of Life issues. I spent several hours reading all your posts, and I wanted to thank you for writing.
I want to apologize for my basic English, but I hope you'll understand. I wish I could write like you do…
I am a family physician in a Kibbutz in Israel and I take care of almost all the people in the Kibbutz, from birth to death. I am faced with end of life issues quite often, and I feel that I have the exact same views on this like you. I am fortunate to be able to help many patients and families to avoid futile hospital care, and this is one of the things I am very proud of.
A few months ago I took care of my stepfather who lived in a fancy place for old people who can take care of themselves and live alone in a nice flat, but they have a restaurant, have cultural activities etc, in a big city. (I don't know what this kind of place is called in English – here it's called something like "sheltered living"). At the age of 89 he started getting weaker and needed more and more help with his daily activities, until finally he needed constant care. Cancer was diagnosed. We got someone to take care of him 24 hours a day. When he got to the stage where he needed a wheelchair the management of this place did whatever they could to get him to leave – to a nursing home (with four people in a hospital bed in a room), a hospital or whatever. He had already sold his previous home, and he expected to live in this place for the rest of his life. He was alert and understood they wanted to get rid of him, as this spoiled their nice place for "the young at heart". They referred me to the contract where it says that this is a place for independent people. I managed to take care of him in his flat and refused to take him to the hospital, as this was his explicit wish, and we all knew that there was nothing they could do better in the hospital than we could do in his own home and bed. In the last week of his life I was there most of the time, gave him medications against pain, and he passed away in his bed surrounded by those who loved him. I was very happy to have been able to do this for him. I was very sad that this had to be done fighting the management all the way. They threatened me that I was denying him adequate care in a hospital, where he should be in his situation. I ignored them as I knew his time was getting short, and I didn't believe they would try to evacuate him forcefully in his situation. He passed away a day before another meeting they set up to tell me I had to take him somewhere else.
So I am glad to read your stories that show me that I am not alone in the thought that if there is nothing more medicine can do the best place for a person to finish his life is in his own home, if this is what he wants.
All the best, Mira Leibovich, MD - Israel"
Thursday, October 6, 2011
Honor the Advance Directive - or Not?
I gave a lunch time talk at a retirement home today to a group of about 60 pretty bright folks including judges, chaplains, professors, etc. The subject was "Your Life Your Choices", a program oriented toward educating families about the value of advance planning and how to make their values and wishes known. The discussion was dynamic and lively.
One consistent point about advance directives is to preserve the patient's autonomy for decision making by having a person "close to their heart" act in their behalf when the patient is no longer competent.
After the session and discussion, a lady quietly approached me and asked if she could have a moment of my time. She said, "My husband has worsening Alzheimer's and can no longer care for himself reliably. He's been transferred to the Memory Care Unit. The doctors say he is no longer competent to make any health care or financial decisions so the burden is entirely on me, but I have a problem. My husband said a few years ago and signed the papers that he would want full life support including fluid and nutrition to sustain him. But I don't know if that's the right thing to do now."
My first thought was to advise her to meet with her doctor and a palliative care or hospice provider to look at all the options with their benefits and burdens. Also I advised meeting with a social worker and/or a spiritual counselor to explore the difficult decisions and to meet as an entire family unit. Then I asked her, "Do you think if your husband's heart stops that CPR would benefit him?"
"No," she replied. "But I'm not sure what his wishes in his present situation would really be. He never talked about quality of life issues much."
I tried to reassure her that there were no clear guidelines in this situation. To try to take the burden off a bit, I told her that doctors in general didn't feel obligated to provide treatments to patients that are not beneficial. She gave me a sad smile saying, "thanks, but I still don't know what to do."
Comment: It can at times be very difficult for a surrogate to truly know the wishes of the patient who is ill and can't further discuss their status. That's why I encourage patients to write an addendum to the Living Will giving their overview of "quality of life." What are the biggest hopes and biggest fears about the end of life? What would be acceptable or when to "pull the plug"? The more we can let our surrogate know our true feelings, the better the decision will be, but it's hardly ever easy in the gray zone such as with this patient.
An example of fear is the story of Chopin's heart. His great fear was being buried alive so he had his physician promise to remove his heart at death, thus ensuring he was dead! Chopin is buried in France but the heart is enshrined in a church in Poland, a significant tourist draw. Chopin's wishes were honored. May we all have surrogates that know our own hearts.
One consistent point about advance directives is to preserve the patient's autonomy for decision making by having a person "close to their heart" act in their behalf when the patient is no longer competent.
After the session and discussion, a lady quietly approached me and asked if she could have a moment of my time. She said, "My husband has worsening Alzheimer's and can no longer care for himself reliably. He's been transferred to the Memory Care Unit. The doctors say he is no longer competent to make any health care or financial decisions so the burden is entirely on me, but I have a problem. My husband said a few years ago and signed the papers that he would want full life support including fluid and nutrition to sustain him. But I don't know if that's the right thing to do now."
My first thought was to advise her to meet with her doctor and a palliative care or hospice provider to look at all the options with their benefits and burdens. Also I advised meeting with a social worker and/or a spiritual counselor to explore the difficult decisions and to meet as an entire family unit. Then I asked her, "Do you think if your husband's heart stops that CPR would benefit him?"
"No," she replied. "But I'm not sure what his wishes in his present situation would really be. He never talked about quality of life issues much."
I tried to reassure her that there were no clear guidelines in this situation. To try to take the burden off a bit, I told her that doctors in general didn't feel obligated to provide treatments to patients that are not beneficial. She gave me a sad smile saying, "thanks, but I still don't know what to do."
Comment: It can at times be very difficult for a surrogate to truly know the wishes of the patient who is ill and can't further discuss their status. That's why I encourage patients to write an addendum to the Living Will giving their overview of "quality of life." What are the biggest hopes and biggest fears about the end of life? What would be acceptable or when to "pull the plug"? The more we can let our surrogate know our true feelings, the better the decision will be, but it's hardly ever easy in the gray zone such as with this patient.
An example of fear is the story of Chopin's heart. His great fear was being buried alive so he had his physician promise to remove his heart at death, thus ensuring he was dead! Chopin is buried in France but the heart is enshrined in a church in Poland, a significant tourist draw. Chopin's wishes were honored. May we all have surrogates that know our own hearts.
Wednesday, October 5, 2011
Saving Health Care Costs the Easy Way
How would you like to have physicians in the USA cut health care costs by more than 6 billion dollars a year in a rather simple non-painful way? A recent study in the Archives of Internal Medicine looked at rather commonly done tests and prescribed medications.
The National Physicians Alliance (NPA) initiated a project called “Promoting Good Stewardship in Clinical Practice.” They have published lists of the “top 5” activities in primary care (family medicine, internal medicine, and pediatrics) that could improve both care and the use of clinical resources. After testing showed physician support for these evidence-based, cost-saving, easy-to-implement activities, the group published their lists with simple guidelines like:
1. Don’t do imaging for low back pain within the first six weeks unless red flags are present.
2. Don’t obtain blood chemistry panels or urinalyses for screening in asymptomatic, healthy adults.
3. Don’t order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients.
4. Don’t use bone-density screening for osteoporosis in women under 65 or men under 70 with no risk factors.
5. Do use only generic statins when starting lipid-lowering drug therapy.
The biggest savings was by the use of generic statins, but all of these five steps were well supported by medical evidence and had peer group support.
If medicine were a large business with careful accounting and accountability, these five steps would be implemented (or the manager fired). But we have a large messy expensive system with little accountability.
Can we step up to evidence based peer supported medical practice? Otherwise I fear the cuts (which are coming) will be painful and illogical.
The National Physicians Alliance (NPA) initiated a project called “Promoting Good Stewardship in Clinical Practice.” They have published lists of the “top 5” activities in primary care (family medicine, internal medicine, and pediatrics) that could improve both care and the use of clinical resources. After testing showed physician support for these evidence-based, cost-saving, easy-to-implement activities, the group published their lists with simple guidelines like:
1. Don’t do imaging for low back pain within the first six weeks unless red flags are present.
2. Don’t obtain blood chemistry panels or urinalyses for screening in asymptomatic, healthy adults.
3. Don’t order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients.
4. Don’t use bone-density screening for osteoporosis in women under 65 or men under 70 with no risk factors.
5. Do use only generic statins when starting lipid-lowering drug therapy.
The biggest savings was by the use of generic statins, but all of these five steps were well supported by medical evidence and had peer group support.
If medicine were a large business with careful accounting and accountability, these five steps would be implemented (or the manager fired). But we have a large messy expensive system with little accountability.
Can we step up to evidence based peer supported medical practice? Otherwise I fear the cuts (which are coming) will be painful and illogical.
Thursday, September 15, 2011
Can We Talk About Death?
"Medical training rarely deals with helping the dying patient find peace and comfort. In fact, most physicians are uncomfortable with the entire subject. I believe it is one of the most neglected aspects of medical care. I have spent my career as a pulmonary and critical care physician, and I have cared for thousands of dying patients. In many cases, both the patients and I knew that they were dying. After I provided clinical and supportive care, I would walk away from their bedside and go on with my work and go home to my family. Now the world has turned around for me. I have widespread metastatic disease to my lungs and bones."
This was written by the prominent physician educator Roger Bone as he was dying and exploring the classical literature about death and dying. In Bone's extensive search of classical literature he found little to explain death itself. "In summary, the great classics, the most significant works in literary history, have had a seminal effect on the behavior and attitudes of our world today, concerning themselves as they do with the issues of love, tragedy, seduction, pride, intrigue, suspense, murder, vanity, fantasy, evil, cruelty, greed, adultery, deceit, depression, fear, brutality, hypocrisy, pride, chivalry, heroism, romance, honor, loyalty, and friendship. But only rarely do they deal with an understanding of death. Notable exceptions include the passages visited above, most memorable in the scene of Beth's death in Little Women, Emily's death in Our Town, and Thoreau's observations in Walden. I examined the classics closely for answers and was left with the conclusion that if you have limited time, read Thoreau, Alcott, and Wilder."
Perhaps we can get a glimpse about the "D" word from authors. "Dying is a very dull, dreary affair. And my advice to you is to have nothing whatever to do with it." (Somerset Maughan) Perhaps the denial that we all have is healthy to some degree, but ultimately harmful when we have to face and plan for the inevitable.
"It's not that I'm afraid to die, I just don't want to be there when it happens." (Woody Allen) The point here is that we really do have some fear, and that denial can be humorous as long as we're not facing a real crisis.
"Life is pleasant. Death is peaceful. It's the transition that's troublesome." (Isaac Asimov) I often heard this from patients, "It's the dying I'm afraid of!"
Advance planning is something we, as a society, don't do well. Most of us tend not to save adequately for retirement, don't execute wills, and don't complete advance directives. Appropriately we tend to live in the present, "the now". So how do we deal with educating ourselves, our leaders, and our governments to balance "the now" with "the future". Ultimately the education about advance planning needs to come from the heath professions, medical societies, communities, states, and the federal government. Viewing this as a public health issue with the rapid aging of the population, the CDC has created a program to educate heath professionals.
None of this, of course, really addresses the mystery of what follows death. Roger Bone found his comfort in the Bible, Helen Keller in Swedenborg's writings in Heaven and Hell, but the journey remains ours alone, hopefully with our creator gently carrying us.
This was written by the prominent physician educator Roger Bone as he was dying and exploring the classical literature about death and dying. In Bone's extensive search of classical literature he found little to explain death itself. "In summary, the great classics, the most significant works in literary history, have had a seminal effect on the behavior and attitudes of our world today, concerning themselves as they do with the issues of love, tragedy, seduction, pride, intrigue, suspense, murder, vanity, fantasy, evil, cruelty, greed, adultery, deceit, depression, fear, brutality, hypocrisy, pride, chivalry, heroism, romance, honor, loyalty, and friendship. But only rarely do they deal with an understanding of death. Notable exceptions include the passages visited above, most memorable in the scene of Beth's death in Little Women, Emily's death in Our Town, and Thoreau's observations in Walden. I examined the classics closely for answers and was left with the conclusion that if you have limited time, read Thoreau, Alcott, and Wilder."
Perhaps we can get a glimpse about the "D" word from authors. "Dying is a very dull, dreary affair. And my advice to you is to have nothing whatever to do with it." (Somerset Maughan) Perhaps the denial that we all have is healthy to some degree, but ultimately harmful when we have to face and plan for the inevitable.
"It's not that I'm afraid to die, I just don't want to be there when it happens." (Woody Allen) The point here is that we really do have some fear, and that denial can be humorous as long as we're not facing a real crisis.
"Life is pleasant. Death is peaceful. It's the transition that's troublesome." (Isaac Asimov) I often heard this from patients, "It's the dying I'm afraid of!"
Advance planning is something we, as a society, don't do well. Most of us tend not to save adequately for retirement, don't execute wills, and don't complete advance directives. Appropriately we tend to live in the present, "the now". So how do we deal with educating ourselves, our leaders, and our governments to balance "the now" with "the future". Ultimately the education about advance planning needs to come from the heath professions, medical societies, communities, states, and the federal government. Viewing this as a public health issue with the rapid aging of the population, the CDC has created a program to educate heath professionals.
None of this, of course, really addresses the mystery of what follows death. Roger Bone found his comfort in the Bible, Helen Keller in Swedenborg's writings in Heaven and Hell, but the journey remains ours alone, hopefully with our creator gently carrying us.
Tuesday, August 30, 2011
Why I Didn't Become a Surgeon
Every medical student goes though a process of elimination when deciding what kind of doctor they want to become. We hear the old saying, "Internists know everything and do nothing; Surgeons know nothing and do everything; Psychiatrists know nothing and do nothing; Pathologists know everything and do everything but it's too late." We hear that pediatricians wear bow ties, are short, and love to laugh and play; that surgeons are decisive but arrogant; that proceduralists are "scoping for dollars", that orthopedists have long hairy arms that reach to the floor, that family doctors are the best balanced, etc. There may be grains of truth in the medical school palaver, but I think we decide both based on our experiences during medical school and our own personality (plus the need to repay school loans).
The first case I ever scrubbed in on was an open heart procedure back in 1963. The unfortunate patient had severe aortic stenosis (narrowing of the valve) in the days before artificial valves were invented. Having changed into my scrubs, put on my cap, paper booties and scrubbed in, I meekly entered the inner sanctum of the OR. The head nurse spotted me and immediately barked, "Here take this gown, go stand in the corner and don't do anything until I tell you."
Other staff came in and one by one put on their gown and gloves. This is a little tricky because you can't touch anything, otherwise you're contaminated. As you might suspect, I put my gown on wrong, was barked at again but given a second chance. Finally I was at the side (almost the foot) of the operating table, trying to peek around the two residents assisting the thoracic surgeon. A huge incision was made, a blade much like a small hoe inserted and the handle given to me, "Here, here's your job. Keep pulling on this so I can see. Harder!!"
The left ventricle was punctured bluntly and a curved blade-like instrument inserted up through the aortic valve in attempts to open it up. There were dense calcium deposits so the going was tough. After several tries, the operation was completed, bleeding controlled, and the patient sent back to the surgery floor.
Almost immediately the patient had low blood pressure and a slow heart rate - not good signs. I was asked to sit at the bedside and administered a levophed drip to try to keep him going. He died at about 3AM. At the autopsy, it was found that the wall between the left and right ventricle was punctured, not the aortic valve. I don't know what the surgeon felt. He was the author of the major textbook on thoracic surgery and the author of many papers. This was in the very early days of heart surgery and it had to start somewhere I suppose, but it didn't make me want to be a pioneer.
The pace of the surgical service was amazing. The chief would arrive at 6AM and expect the residents to give him full report on the status of the patients. He would be in the OR from 7 to 9AM, then off to a breakfast with the University Regents. There was a pecking order and pyramid system for the surgical residents' survival. It was very difficult to survive this structure to become a chief resident.
After all this, I chose Internal Medicine and ultimately more training in Infectious Diseases, Pulmonary and Critical Care Medicine. Strangely, the intensity of the ICU isn't that different from the operating room. But in the OR, there is only one leader. You don't break for a conference or try to reach a team consensus. The surgeon is expected to know what to do, to do it well, and to do it fast (better outcomes with less time under anesthesia). As a nurse said, "The surgeon is like a god in the OR".
But surgery is changing. I walked into the ICU to see a post-op consult in recent years, and asked the "nurse" what the vital signs were and her assessment. She kind of smiled and said, I'm the new Urologist and just created an artificial bladder for this patient with bladder cancer. I profusely apologized for my gaff and she let me off gently. In fact at the nurse's desk later, I asked her to explain the surgery. She replied, "It's just sewing. You take a piece of colon, make a pattern, stitch it all together, plug in the ureters from each kidney, and voila!"
Well, although you might see why I didn't become a surgeon, I hope you understand that I have great respect and awe for their arduous training, for their skills, and stamina, and, yes, guts.
The first case I ever scrubbed in on was an open heart procedure back in 1963. The unfortunate patient had severe aortic stenosis (narrowing of the valve) in the days before artificial valves were invented. Having changed into my scrubs, put on my cap, paper booties and scrubbed in, I meekly entered the inner sanctum of the OR. The head nurse spotted me and immediately barked, "Here take this gown, go stand in the corner and don't do anything until I tell you."
Other staff came in and one by one put on their gown and gloves. This is a little tricky because you can't touch anything, otherwise you're contaminated. As you might suspect, I put my gown on wrong, was barked at again but given a second chance. Finally I was at the side (almost the foot) of the operating table, trying to peek around the two residents assisting the thoracic surgeon. A huge incision was made, a blade much like a small hoe inserted and the handle given to me, "Here, here's your job. Keep pulling on this so I can see. Harder!!"
The left ventricle was punctured bluntly and a curved blade-like instrument inserted up through the aortic valve in attempts to open it up. There were dense calcium deposits so the going was tough. After several tries, the operation was completed, bleeding controlled, and the patient sent back to the surgery floor.
Almost immediately the patient had low blood pressure and a slow heart rate - not good signs. I was asked to sit at the bedside and administered a levophed drip to try to keep him going. He died at about 3AM. At the autopsy, it was found that the wall between the left and right ventricle was punctured, not the aortic valve. I don't know what the surgeon felt. He was the author of the major textbook on thoracic surgery and the author of many papers. This was in the very early days of heart surgery and it had to start somewhere I suppose, but it didn't make me want to be a pioneer.
The pace of the surgical service was amazing. The chief would arrive at 6AM and expect the residents to give him full report on the status of the patients. He would be in the OR from 7 to 9AM, then off to a breakfast with the University Regents. There was a pecking order and pyramid system for the surgical residents' survival. It was very difficult to survive this structure to become a chief resident.
After all this, I chose Internal Medicine and ultimately more training in Infectious Diseases, Pulmonary and Critical Care Medicine. Strangely, the intensity of the ICU isn't that different from the operating room. But in the OR, there is only one leader. You don't break for a conference or try to reach a team consensus. The surgeon is expected to know what to do, to do it well, and to do it fast (better outcomes with less time under anesthesia). As a nurse said, "The surgeon is like a god in the OR".
But surgery is changing. I walked into the ICU to see a post-op consult in recent years, and asked the "nurse" what the vital signs were and her assessment. She kind of smiled and said, I'm the new Urologist and just created an artificial bladder for this patient with bladder cancer. I profusely apologized for my gaff and she let me off gently. In fact at the nurse's desk later, I asked her to explain the surgery. She replied, "It's just sewing. You take a piece of colon, make a pattern, stitch it all together, plug in the ureters from each kidney, and voila!"
Well, although you might see why I didn't become a surgeon, I hope you understand that I have great respect and awe for their arduous training, for their skills, and stamina, and, yes, guts.
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