Monday, March 13, 2017

What's the ICD-10 for "Fucked-up healthcare system"?

Details changed, it's all fiction, I'm really a 400 pound Ukrainian hacker, etc.:

Differential diagnosis includes [but is not limited to] fracture, laceration, abrasion, contusion, hematoma, ligamentous injury, vascular injury, nerve injury

In summary, this is a 29-year-old male who has done his utmost to follow the plan laid down for him when this tibial plateau fracture was dx a week ago. He has followed up with his primary. He elicited a list of possible surgeons directly from his insurance company. He called ALL surgeons listed as accepting his insurance. Five would take him, but have no appts in the next month. He then appropriately returned to his primary, who then referred him back to our ED.

I spoke at length regarding this case to Dr. It’s-2a. Not only would he not see or treat the patient, he was emphatic that the consultation itself was inappropriate and that it was a social work issue. Despite that his expertise was of benefit in that he set the maximum time the surgery, ideally obtained btw 7-10 days, could be delayed (two weeks from the injury, leaving four business days for Mr XXX to overcome the hurdle of not having a orthopedic doctor who would see him within a month, obtain a consult with them, and be scheduled for and obtain surgery) and advising that Mr XXX's coldness/swelling, in the setting of normal pulses and sensation, likely reflected a need to keep the leg elevated more consistently to reduce edema. Appreciate his consultation.

As the initial trauma was caused by a motorcycle accident, OSH YYY trauma service agreed to accept Mr XXX in transfer and, in their words, "work something out." Very grateful to them for their help with this extraordinarily frustrating case of an insured patient who seemingly "did everything right" but nevertheless was not able to obtain critical time-sensitive follow-up care.

Wednesday, September 28, 2016

Technology and the Old Masters

Boy, do I have feels about this. Feeling number one: it’s complicated.

While it’s great to have all the skills, technology will inevitably cause the loss of some older ways of doing things. I’m sure the first OB/Gyn residents to graduate without knowing their way around a foreceps delivery faced some scorn from their colleagues. A few years after Laennec, there undoubtedly was an old-timer who complained to another old-timer to the effect of “Kids today, they don’t even know how to auscultate a chest without their fancy amplifying wooden tubes.” Somewhere in the mists of history, shortly after the introduction of practical glucose assays, there was somewhere a great teacher who complained bitterly about young physicians who didn’t even know the the taste of diabetic urine.

On the other hand, it’s a good idea not to let go of all the low(er) tech ways of doing things, as you made need them when your high-tech gadgets fail you. And high tech or low, it is alays better to have more than one way to do something.

But even so, we have to remember that time and opportunities to practice are limited. “Learn both” is easy to say but hard to practice. If we’re being intellectually honest, we should accept that we already use the training time allotted to the making of a doctor, and if you want to add something you should be prepared either to increase the hours of training or cut something out. And the natural thing to suffer when you introduce a new way of doing a task is the old way of doing a task: patients will not likely suffer twice as much respiratory failure for your convenience in learning and practicing the Glidescope and manual laryngoscopy both.

Which brings me to feeling number two: it’s too early to say goodbye to landmark-only lines. Some rooms are too small, some patients too critical for ultrasound. Machines number one or two in most EDs; they may all be in use.

What you come out of residency knowing how to do is in large part a reflection on your teachers. This physician, I'd wager, trained somewhere where it was ultrasound-guided IJs, all day every day. Tell someone at that program you wanted to put in a blind fem line to learn how to do it and they'd look at you like you just grew a second head.

This is why once you have trained up your residents a bit it's important to put them out on their own, or close to it, in a place where hairy stuff can go down. Code teams. Night shift in the ICU. EMS months. Moonlighting. In those situations the need for hairy shit like a STAT femoral line arises organically.

But this is contrary to the entire thrust of medical culture as it has developed in the last 30 years. In the name of safety, every learner must be supervised at all times. Consequential decisions are left to the higher ups. Uncontrolled and semi-controlled crises, which arise with sick patients all the time, make administrators' skin crawl and they strive to keep residents as far away from them as possible. When something bad occurs, the refrain goes up, "Only the attending should be entrusted with this" -- an attitude that does little for safety, by and large, but quite effectively stunts learning.

What Samuel Shem wrote in the House of God is still true today: doctors learn "by taking risks in those hard times when you were alone with your patient." If you never leave a doc alone, because safety, well…this is where you end up, with physicians that function fine in routine situations but poorly when Death shows up and decides to eat their lunch.

Final feel: education aside, by five years out you should have a good idea where your holes are and be working to fill them. I can put in blind femorals by pulse or landmark (when there is no pulse) as well as under ultrasound; I can put in a blind subclavian with confidence, and my ultrasound guided IJs are respectable. Am I satisfied? Hell no! I want to learn how to use ultrasound at the subclavian and how to do a blind IJ. I've recently started to use Statlocks to secure the lines instead of sutures (fewer holes in the patient, less line infections.) Constant practice of what you know; constant reaching for new and better techniques and tools. The old ways will slowly pass out of knowledge, but a physician humble in their limited knowledge but restless and impatient for perfection will never go out of style.

For always roaming with a hungry heart
Much have I seen and known; cities of men
And manners, climates, councils, governments,
Myself not least, but honour'd of them all;
And drunk delight of battle with my peers,
Far on the ringing plains of windy Troy.

Monday, September 5, 2016

Quit bitching and love your hospitalists

The New England Journal of Medicine has some issues with hospitalists:
In fact, increasing reliance on hospitalists entails a number of risks and costs for everyone involved in the health care system — most critically, for the patients that system is meant to serve. As the number of physicians caring for a patient increases, the depth of the relationship between patient and physician tends to diminish — a phenomenon of particular concern to those who regard the patient–physician relationship as the core of good medical care.
Practically speaking, increasing the number of physicians involved in a patient’s care creates opportunities for miscommunication and discoordination, particularly at admission and discharge. Gaps between community physicians and hospitalists may result in failures to follow up on test results and treatment recommendations.1 Moreover, the acute care focus of hospital medicine may not match the need of many patients for effective disease prevention and health promotion.
Practically speaking, this is high-minded nonsense. Of course it would be ideal to have one physician caring for you from cradle to grave, with a light garnish of various specialists. This model, which was merely slow and inefficient 30 years ago, when it began its sharp decline, is now, in 2016, impractical and unsafe. But aside concerns of cost or time management: hospitalized patients in 2016 are too sick, too old, and too complex for the vast majority of primary care practitioners.

A hospitalist requires, in part, a thorough knowledge of the diagnosis and acute management of heart attack, stroke, sepsis, hemorrhage, DKA, HHS, DVT and PE, pancreatitis, cardiac arrest, COPD exacerbation, severe asthma, cholecystitis, hepatitis, alcohol withdrawal, status epilepticus, endocarditis, meningitis, myesthenia gravis, and I could go on and on (and on.) On the floor in the dead of night with a patient who has developed hypotension, or new neurological deficits, or severe chest pain, referral is impossible and in most settings bringing a consultant to the bedside is almost as impractical as referral.

Not only is extensive training and experience with many acute conditions required (something most primary care doctors today have little, if any, experience with), significant procedural experience is required and must come from somewhere. If an internist today does not know how to put in a central line, intubate a patient in respiratory distress, or place a chest tube, then someone must be on hand who can perform these tasks, typically an emergency physician or a ICU specialist. 

But it is not desirable to pull either the emergency physician out of the department or the intensivist out of the ICU. In either case, you may be borrowing the only physician staffing some severely ill and potentially unstable patients. Yet only 11% of hospitalists in one large national survey performed are nine of the procedures identified as "core competencies." As underwhelming as this is, it compares to a mere 3% of non-hospitalist internists in the same study!

As much as the NEJM may not want to hear this about their loyal subscribers, 21st century primary care physicians do not have either the cognitive tools or the physical skills to manage sick inpatients.

Today's primary care physician pushed into the hospitalist role would give us less coordinated care, rather than more. When you put any doctor in a position where the task at hand is beyond their training and experience, they do one thing very reliably: they call a consultant. They would consult EPs, critical care doctors, GI doctors, endocrinologists, cardiologists and so on, with great vigor (even more so than today's hospitalists, who have never been accused of being dilatory in this). The result would be even more doctors trying to drive the bus, even more opportunities for miscommunication and misunderstanding.

Look, I get it. Change is hard. Some people don't see quite where hospitalists fit in the grand tradition of the golden age (real or imagined) of American medicine:
For most of medicine’s history, however, the boundaries of medical fields have been based on factors such as patient age (pediatrics and geriatrics), anatomical and physiological systems (ophthalmology and gastroenterology), and the physician’s toolset (radiology and surgery). Hospital medicine, by contrast, is defined by the location in which care is delivered.…

The very term “hospitalist” seems problematic. If we call some physicians hospitalists, should we call others “clinicists” or “officists”?3 Similarly, the move toward shift work may open the door to “matinists” and “nocturnists.” Using a misnomer such as “hospitalist” to mean acute care medicine may seem harmless, but calling things by the wrong names is often the first step toward becoming confused about them — a particularly hazardous state of affairs for a profession facing an era of great flux.
Guess what? A LOT of medical specialties are defined by where they work, by the type of patients that present there and the types of problems they have. A partial list would include emergency physicians, anesthesiologists, primary care physicians ("officists" indeed,) as well as hospitalists. Is that somehow less legitimate, less dignified than being defined by a toolset or a system?

The hell it is. As medicine has become more and more specialized, more and more physicians specialize in saying no -- no, I'm not on call, the office is closed, no you need a specialist, or you need a subspecialist, or different insurance, or anything and everything -- but hospitalists, like emergency physicians, specialize in saying yes. When you come to the hospital, they roll up their sleeves and get to work. That is the true physician spirit, which the NEJM would denigrate in a misguided attempt to save it.

Friday, December 5, 2014

How nostalgia killed Dr Singer's capacity for rational thought


A Facebook friend recently has been sending around a 2013 article/toddler-grade tantrum by Dr Jeffery Singer, general surgeon/old man sitting on a park bench. Let me tell you, it's a tear-jerker:

These rules are being bred into the system. Young doctors and medical students are being trained to follow protocol. To them, command and control is normal. But to older physicians who have lived through the decline of medical culture, this only contributes to our angst.

One of my colleagues, a noted pulmonologist with over 30 years’ experience, fears that teaching young physicians to follow guidelines and practice protocols discourages creative medical thinking and may lead to a decrease in diagnostic and therapeutic excellence. He laments that “ ‘evidence-based’ means you are not interested in listening to anyone.” Another colleague, a North Phoenix orthopedist of many years, decries the “cookie-cutter” approach mandated by protocols.
God forbid you should go to work and find rules "bred into the system" that restrict your ability to do whatever the hell you feel like doing. I'm sure no one but doctors ever feels that pain.

This all seems very sad, but when a doctor opines that evidence-based medicine "means you are not interested in listening to anyone" you have to understand that as code for "You aren't listening to me." Because until startlingly recently, that's how virtually all medicine worked; the leading lights of the profession laid down the law, and that was the standard of practice.

There are now standardized grades of evidence, starting with multiple randomized controlled trials and extending downwards through observational studies and case reports and at the very bottom, "expert consensus" (i.e., this is what we believe but we have no proof of any kind.) This quality of evidence is known colloquially in the industry as GOB-SAAT. Good Old Boys -- Sitting Around A Table. Before evidence-based medicine, we had eminence-based medicine.

Dr Singer's hatred of protocols -- things like washing your hands between patients, pausing before surgery to confirm you're doing the right surgery on the right patient, or observing low-risk head injuries in children rather than irradiating their brains -- is common in physicians, but in Dr Singer, it has been amplified by ideology:
Ayn Rand’s philosophical novel Atlas Shrugged describes a dystopian near-future America. One of its characters is Dr. Thomas Hendricks, a prominent and innovative neurosurgeon who one day just disappears. He could no longer be a part of a medical system that denied him autonomy and dignity. Dr. Hendricks’ warning deserves repeating:

“Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”
What are we to think of a man with a responsible job and most of his career behind him who has the intellectual interests of a socially stunted 14-year-old? These are questions I cannot answer.

To try and interest us in what is essentially an irrelevant paean to his own nostalgia, Singer's lards up his argument with predictions of disaster aplenty (All the doctors will quit! Except for the brain-dead younger generation weak enough to tolerate the intrusion of "so-called 'evidence-based medicine,'") some of which are really funny in their own right:
 In other words, we’re about to experience the two-tiered system that already exists in most parts of the world that provide “universal coverage.” Those who have the financial means will still be able to get prompt, courteous, personalized, state-of-the-art health care from providers who consider themselves professionals. But the majority can expect long lines, mediocre and impersonal care from shift-working providers, subtle but definite rationing, and slowly deteriorating outcomes.
Yes, if nothing is done, we will soon experience the universal free healthcare that delivers better health outcomes at half the cost in the UK and Canada -- a model so wildly popular in those countries that right-wind politicians get nowhere near office without swearing to protect and defend it.

But the real punchline here is his claim of "slowly deteriorating outcomes." The outcomes are better than ours, but in the confines of Dr Singer's Rand-poisoned mind, that simply means they are deteriorating too slowly for the terrible and inevitable decline to be evident to the causal observer.

Back in the reality-based community, things look rather different:
The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland (Exhibit ES-1).
Protocols have good and bad points. I deal with frustrating and clinically counterproductive protocols every day. If you are going to spend seven years training a doctor, you should probably leave room in the system for them to exercise their clinical judgement. But many protocols are proven to improve patient outcomes. So if they make our days as doctors a little less fun, so be it. And evidence-based medicine, like free speech, is best answered by more and better evidence, not nostalgia for the days when the stand of care was "I got a hunch." Fuck GOB-SAAT.

Monday, October 20, 2014

Thoughts on Placebos

CarbonKyle, scourge of alternative medicine and pseudoscience of all sorts, has some negative things to say about placebos in the comments here. As a frequent user of what one might term semi-placebos (things I hope will help a little, but are primarily recommended to give a non-harmful treatment whilst the body heals itself) I felt I had to speak up for the humble placebo:

I recommend "The House of God" for a medical perspective on the value of, as Shem puts it "Doing as much nothing as possible."

Allopathic medicine prescribes a lot of ineffective or unnecessary medicine -- these are really placebos by another name. The difference is that while a good placebo is harmless, a bad placebo -- like an antibiotic for a viral pharyngitis or a muscle relaxant for back pain, or (a horror that takes place 250k times a year in the US) an unnecessary heart cath for stable angina -- may have some serious negative health consequences.

Placebos are necessary because treatment is part of the ritual of healthcare. Listening, helping the patient make sense of the problem, and offering treatment all have a value in themselves, apart from the biomechanical efficacy of the treatment (or even whether the diagnosis is correct.)

It's true that many people find the explicit use of placebos unethical, and it may be. But if you were to ask a hundred doctors "Have you ever prescribed a treatment you didn't believe would cure the patient, in order to give a patient something, knowing that the disease was going to get better in time regardless?" 90% of them would say yes (and the other 10% are lying.)

The physician has a different role than the scientist. The purpose of the scientist is to seek empirical truth; the purpose of the physician is to seek healing. And to do that, our mandate is broad:

"Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and external circumstances cooperate."

Thursday, October 9, 2014

"Informed" "consent"

Dr Orthochick over at Fizzy's place is talking consents.

It's a tangent, but I find myself a huge skeptic/cynic of/about the whole concept of informed consent. This is of course supposed to be our antidote to the bad old paternalistic days when you would want some information about what was going to happen with your condition and your care and your wise old doctor would pat you on the head, take a long drag of his unfiltered Camel, and tell you not to worry your pretty head about it.

But the concept of informed consent does not make very much sense, philosophically, nor is it particularly practical. Informed consent is supposed to include "PARQ," shorthand for "procedures, risks, alternatives, and questions." The big daddy here is risks; that's what we talk most about. The risks of doing a thing and the risks of not doing it. And then you get to chose. Sounds great! But how am I supposed to give you an accurate account of the possible risks of something I want/need to do for you? There are always dozens of things that can go wrong, some minor, some major.

Obviously the significance of each particular risk depends on how likely it is to come to pass, which is a statistical question. But most people (including most physicians) are not good with statistics. We tend to overrate rare risks, underrate things we haven't seen personally, make big changes in response to one bad experience, etc.

Practically speaking, in the best case I tell you and you understand whether a risk is rare or common. But if it's rare, you probably don't need to worry about it, and if it's common, it's probably minor. (Informed consent would be really useful if doctors commonly performed unnecessary procedures that killed or crippled half the people who had them, but for obvious reasons, we don't do that.)

So what you're left with are rare serious risks, to which it will be difficult to assign significance to because they are rare, and common minor risks, which neither you or I care much about.

Sometimes people have strong opinions about their care, and sometimes they have a much greater tolerance for one kind of risk (kidney failure from a coronary angiogram) versus another (a heart attack like the one that killed their father.) And sometime people are done with medical care, and they want to slow down or stop -- that's a really important discussion to have.

Most of the time, though, people don't have the medical or statistical expertise to weigh all the risks and benefits of a particular course of action -- that's what they pay me for. And they know that. Most people are going to do whatever it is you recommend as their doctor (at least in the emergency setting, where I work). And that's really the only rational course, when you hire a professional to help you do something you don't know how to do yourself.

It's not about the doctor thing. If I hire an IT person to fix my computer, and they tell me I have too many zeroes and I need to buy more ones, then that's what I'm going to do.

So at the end of the day, the real "informed consent" boils down to this: Do you trust me? Do you feel like I care about you? Do you think I am careful and competent?

If you do, and I recommend something, you should do it. If you don't, then regardless of what I say, you probably shouldn't.

You can't take the trust out of the doctor-patient relationship. Every patient (with decisional capacity) should have all their questions answered, know what's happening, and have veto over any and all things being done to their bodies. But on a daily basis we assault patients' ears and brains with a mountain of complications and terrible possibilities that they can't possibly weigh and measure, even well, and we badger them to make important decisions when they are hurt, scared, and sick, all in the name of a chimera called "informed consent."

But the only decision they are really making, most times, is: Do you trust me?

Tuesday, November 8, 2011

The roadwork

Joe Frazier passed away last night. He died, at the age of 67, of liver cancer. Among many accomplishments, the great heavyweight champion uttered the best quote about medical education (or any other sort of preparation) I have ever heard:

You can map out a fight plan or a life plan, but when the action starts, it may not go down the way you planned, and you’re down to your reflexes – that means your training. That’s where your roadwork shows. If you cheated on that in the dark of the morning, well, you’re going to get found out now, under the bright lights.
- Joe Frazier