Flight plans and unexpected turbulence

One of my patients recently found out that he has a terminal condition, and he is thunderstruck. He refuses to accept that this is the end. He says to me, "I can't just give up!" He tells me that he is going to beat this thing and win, and that he still has a fighting chance. But he doesn't. And I really want him to come to grips with this, because I want to make the end as pleasant as I can, and not misery.

And that's the problem of thinking of disease like a sporting event or a battle, because ultimately, everyone dies. Even if you win the game, the game is over. This is something you learn to come to terms with in internal medicine. Maybe a pediatrician or a subspecialist can insulate themselves from this reality, but my job is to try to extend longevity as much as can be reasonably done. I don't save any lives. All my patients are going to die, and likely while I am at the helm.

When thinking about life, I always preferred the metaphor of flying a plane. Every plane goes up, and every plane lands, and we want to go as far as we can, as comfortably as possible. And we don't get to choose our plane. We could get a Cessna, or a G6, or a Concorde, or even a 747. There's no choosing. We get the plane we get. But regardless of the plane, we're mostly all are trying to fly as far as we can and as comfortably as possible.

There are factors that we can modify. We can avoid bad weather or change our flight plan or change altitude or throttle. Maybe we know to do these things, because we got an airline transport pilot licence, and then we paid for good fuel, rigorously checked the flight plan, and had the best mechanics look over the plane with a fine tooth comb. Or maybe we never got a pilot licence because it was too expensive. Or we started out in a terrible airport surrounded by terrible weather conditions. Or maybe we didn't have any radar or doppler, and had to trust our gut about the weather. And maybe we didn't even know that these were things to worry about till we were already halfway through our fuel. Or maybe we decided to have some fun and did a whole bunch of air stunts, not realizing that it might cause stress damage. There are so many modifiable factors, and we can try our best to maximize our chances of flying far and smoothly, but in spite of our best planning, we could have a catastrophic failure of some little hydraulic tube that changes all of our plans.

And if something catastrophic happens, then it's not guaranteed that we are doomed. Maybe we can recover and still complete our flight plan. But some catastrophes we know will have no recovery, like if the fuselage gets ripped in half or a wing tears off. We're not going to make it to our destination. We're going to crash.

As a doctor, if I know we're going to crash, then my job changes. I'm no longer trying to help us get to our intended destination, but now I am trying to get us close to a nice landing spot, and help us land as smoothly as possible. Because there are bad crashes where no one walks away, and there are 'good' crashes where the survivors look back and think how lucky this was, given the circumstances. And so I'm pointing out to ease up on the throttle, avoid this weather cell, aim for this strip of highway, radio ATC and let them know of our situation, so there can be resources ready to meet us on the ground: medical personnel, fire crews, police to clear the scene. And I can't do any of those things if the pilot is not ready to concede that yes, this plane is crashing and we have to make the best we can of this terrible situation. No one wants to crash. But if that's your only choice, then I can help.

What comes next

​One of my patients had a major event, and very nearly died. It was very touch and go, and after several months, she is finally on the path to recovery, and I was a little surprised that she pulled through, because of all of my patients, she is the most accepting of death. She's been a widow for years, and we frequently have talked about how she is ready to go. So I was surprised to see her clinging to life with such tenacity. She is not going without a fight, the person I had thought to be the most eager to have her ticket punched. 

Life is funny sometimes like that. On the news sometimes, you see people ready to commit suicide, and at the very moment they are ready to leap, they grab onto the edge desperately. There's a line in "Crime & Punishment" by Dostoevsky where he says:
... where was it that I read of how a condemned man, just before he died, said, or thought, that if he had to live on some high crag, on a ledge so small that there was no more than room for his two feet, with all about him the abyss, the ocean, eternal night, eternal solitude, eternal storm, and there he must remain, on a hand's-breadth of ground, all his life, a thousand years, through all eternity - it would be better to live so, than die within the hour? Only to lie, to live!
I don't know what comes in the next life, but I don't have much expectation for what remains for me in this one. Maybe I will have a different perspective when I am in my eighties, but if I look at my life honestly, I am already coasting in neutral. I really wonder if when my time comes, will I also grab onto the edge?

5 minutes

There is a lot of research and publications about different interventions during patient encounters. A brief smoking cessation intervention, a brief psychological assessment, a brief social stressor history, a targeted exam to identify depression, get up and go, cognitive evaluation, MMSE, MoCA, GAD7, PHQ9...

When I went to a productivity seminar, the speaker noted something very straightforward. The only truly fixed quantity we have in life is time. Everything takes time. Sleep takes time, eating takes time, fun takes time. There is nothing in life that we do not value with time, and there is only a limited time that we have, in a day and in a life.

I have 15 minutes to make a change in a person's health. That is my fixed quantity. In that time, there are things that have to happen, things that can be quicker or slower, and when everything is tallied up, I have -3 minutes. It is no longer a question of which brief intervention I can fit in, but what required thing can I cut out? Can I skip diabetes management this time? Can I ignore the BP until next visit?

So when I am less than enthusiastic about your presentation on a 5 minute intervention on fall risk or a new screening tool for domestic violence, please understand that I agree it's important, but is it more important than a BP of 185/105? Is it more important than signing a patient up for a patient assistance program?

n=1

We are constantly talking about all of these people in this country who are dying from medical errors. According to a recent publication, it is the third leading cause of death in the US. But who is doing all this killing, because it's certainly not me, right? I haven't killed anyone because of any mistakes. But statistically, I have to be a part of this number. I made some little something somewhere, that when added up on a balance sheet, pushed someone from the "alive" column" into the "dead" column. But it's hard to know what to do about this, personally. As a system, there are lots of things that organizations do, like tracking and labeling, human factors engineering, checklists, etc. etc. But what can I do?

In medicine, we talk a lot about "n=1" studies. In a research protocol, n is the number of participants in a study. The bigger the n, the more powerful the study to make a conclusion. But in practice, it is those n=1 studies that influence our behavior. I missed a cholangiocarcinoma whose only significant finding was a mildly elevated alkaline phosphatase. That was my only clue, and I dithered. And now, I'm suspicious of every alk phos elevation, constantly wary of missing this diagnosis. But it is a fairly uncommon cancer. I'll see tons of breast and colon and prostate and lung cancers in order to see one more cholangiocarcinoma. Of the 454 cancers found yearly per 100,000 population, cholangiocarcinoma makes up 1-2 total. There will be 452+ other cancers that I am going to see before I see another one. But here I am, fretting about a mildly elevated alk phos, wondering if I should get an MRCP.

A friend of mine described being a doctor as being continuously haunted by ghosts. There is always some ghost of a previous patient hanging over you, reminding you of your mistakes and failings. And it takes a fair bit of bravery to count up those ghosts and look for any patterns.

The right thing

Recently, I had to go to a meeting where we reviewed our HCAPS scores and other quality metrics. If you don't know what these are, then you're lucky. And we've had industry experts come in and talk to us about "Here's how to get your HCAPS better!" or "Shaving down your length of stay" or some other talk, in order to game our numbers and earn ourselves a few extra nickels. Most of the time, I play on my phone the whole time, or zone out completely. I have open disdain for such talks, not because quality of care is important, because it is. Quality of care is extremely important. But average LOS and HCAPS and HEDIS and all these quality metrics are all surrogates. I can make those numbers better, but that doesn't mean that I'm a good doctor.

However, one of these speakers said something that reached me. "The most important thing," he started. "...is that we do what is right for our patients. That's job #1. Then, we should figure out how we can get paid better for it. But even if we can't get paid better, at least we know we did what is right."

I spend a lot of time doing what is right, rather than what is expedient or what gets me more money. And that sounds so estimable and noble, but in reality, that is hard work. That is spending time arguing with an insurance company over a refused prior authorization, or seeing that patient who came in so late to their appointment but with acute problems that can't wait till next week, or spending 5 extra minutes writing a good note that most likely no one will ever read.

I used to be a little bitter that here I was, doing the right thing, and getting no credit for it. As well, there were plenty of others doing a fairly terrible job, and no one was calling them out for it. And it took this line from this industry expert to remind me that the goal wasn't to get credit. The goal was to do the right thing. That's the reward. Getting credit is just a pleasant side effect, should it happen.

When I was in college, I was the proverbial "nice guy" who never got the date with the girl, and I was similarly bitter back then. Here I was, such a nice guy, but ignored by so many women. And I was reminded by a very wise old lady that goodness is its own reward. If you are being nice to women only for the expectation of a reward, then that's not chivalry. That's being a creep.

Too little, too late

Last year, I saw Mr S, a wonderful gentleman in his seventies who was wheelchair bound and required constant supervision. The reason I was seeing him wasn't his paraplegia, but his terrible cholesterol and triglycerides, despite medications. I met with him and his caretaker, and we talked about his diet. In a shining moment of shared decision making and patient centered care, I asked him to tell me about what he eats and where we thought we could make changes. He proceeded to tell me about his diet, but we never got past breakfast. Every morning, he ate sausage, bacon, and 2 donuts.

We discussed what changes he could live with (his caretaker was more than willing to make the changes since her own doctor was fairly critical of her own lab results), and he agreed that he was willing to change his breakfast. He would get rid of the pork products, the donuts, and would change to a hearty bowl of oatmeal and fresh fruit. And his cholesterol and triglycerides improved dramatically. I couldn't wait to see him back in the office for his follow up appointment at 3 months, but the day before the appointment, his family called. He had died.

I can't help but feel that I made this guy's life miserable. He only had a few months left on this earth, and instead of bacon and donuts, he died with a belly full of oatmeal and cantaloupe. If I had known that we were dealing with a few months, what was the point of getting his cholesterol better? In medicine, it's really hard to know when you've been successful. Everyone dies. So what does it mean when one of my patients die? Did they meet their projected life expectancy? Did they get to median survival? The goal posts aren't the same for everyone. Maybe Mrs J who has bad COPD and CAD will be lucky to make it to 75. Maybe Mr O will live to be 100, despite his terrible diabetes.

People tell me that they appreciate the care I deliver, but it is exceptionally hard to know if you are a good doctor. Because the most important metric, are my patients living longer/better, has no control group for comparison.

After Mr S died, I went out to breakfast that weekend, and had pancakes and bacon and sausage. And I poured out some bacon and syrup for him.

Pain of life

I've generally tried to avoid getting into trouble with opioid medications, but in primary care, it's difficult to avoid. There are a lot of people on pain meds. And there's a lot of chronic pain out there. And all the talk these days about inappropriate pain medications, I feel it's disingenuous.

When I was in medical school, it was hammered bluntly into our heads that pain is an important sign, so important that it should be considered the fifth vital sign. We need to treat pain, and we should be ashamed if we lacked the compassion to address pain. We were told that the likelihood of developing abuse was so paltry that it wasn't worth discussion. We were indoctrinated into a culture of pain control that was whimsical and optimistic and did not take any measure of reality. 

Now, we are told that patient satisfaction is critical to excellent care and best practices. If you know an inpatient doctor who has never heard of HCAHPS, then that's one blissfully ignorant dude. And HCAHPS even has several questions that directly deal with pain. As if patient satisfaction has ever correlated with good medical care. It's a hospital, not the Ritz-Carlton. 

But I think that we have a really poor understanding of pain. From both sides of the fence, people do not appreciate that pain is not simple. Pain is tremendously complicated and the factors that govern it are not easily appreciated. I pulled my back in the gym and actually passed out from the pain. I couldn't walk for two days. I didn't take anything because I knew that eventually, the pain would go away. But for my 50 year old patient who was abused as a child and raped as a teen, abused by her ex-husband and abandoned by her daughter, she has no such confidence that her back pain is going to get better, and guess what — it doesn't. And so pain meds make life just a tiny bit more bearable. Is that the appropriate goal of therapy? Is it okay that the pain meds are only there to make the day go by faster? I don't know what the right answer is.