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.