Don't become a doctor #20 - treating the source

​I am fond of telling people that all the advances of modern medicine account for maybe about 3% of the improvement in the health of the human condition. The other 97% of the betterment of humanity can be credited mainly to three things: clean drinking water, sewers, and immunizations. There are some other things too, like labor laws and pollution controls, but pretty much everything we do now in modern medicine is the equivalent of sprinkles atop an ice cream sundae. Your toilet has done more for the betterment of humanity than I ever will.

And really, the future of the improvement of the health of humanity doesn't lie in anything I can do or modify. If I wanted to make the biggest impact in the improvement of the health of humanity for the betterment of the general public, then I would institute universal basic income and mandatory pre-K through 12 education. I can do a lot of things right now: I can treat hypertension and diabetes, I can diagnose and treat complicated medical conditions, but I do not have a pill to treat poverty. I have no prescription for socioeconomic oppression.

Mrs B can't afford her medications. She has Medicare, yes, but she pays a monthly premium for a supplemental plan that only gets her out of pocket expenses down to $10-15 per prescription. How is that going to help her pay for the 8 pills I am prescribing? Best case scenario, that's $80 a month, but she only gets $800 from Social Security, and she spends $500 of that on rent. She literally cannot afford to be healthy. I see her every 3 months for what purpose? The diseases I am treating are not the principal problems of her life. Another $300 a month would make her far healthier than another diabetes medication. Having a blood pressure under 150/90 isn't going to get her electric bill paid. I asked her about it once. 

"I understand that you can't afford to do a lot of the things I'm recommending, but then why keep coming to these doctor appointments? You can save your copay." She was speechless for a moment, like that was even an option. The thought of NOT seeing the doctor is anathema to her. She wants to be healthy. She wants to do better. But she is swimming upstream without a paddle, and that paddle looks suspiciously like another $300 a month in her budget. I do a lot of counseling and education for her, because maybe she can keep up serious lifestyle changes, and maybe that will be an adequate replacement for lisinopril. 

I have a sickle cell patient who is frequently in the ER or hospital. She can't stay in school, can't hold down a job, can't have any semblance of a normal life because for her, a normal life involves spending on average 2 days a month in the hospital or ER. How is she supposed to better herself when she cannot access the tools by which people better themselves? Whenever I see her, I encourage her that she needs to work on avoiding triggers for a crisis. She needs to bundle up warm in the winter. She needs to stay really well hydrated in the summer. She needs to keep active, but not too active. She needs to wash her hands so she doesn't catch any colds. Her life is a constant vigilance to prevent her own body from betraying her. When does she have time for bettering herself, when all of her time and energy is put into avoiding being sick?

In America we always talk about pulling ourselves up by our bootstraps. But really, that assumes you have boots. If you don't have boots, then what? Forget boots, what if you don't have feet? We do not have equal standing in any respect. We do not have equal opportunity, equal adversity, or equal ability. If we do not share equally for the potential of success, then how can we expect people to be successful? So I don't spend much time with the successful. I spend most of my time with the losers on the battlefield of life: the injured, wounded, and crippled from chronic stress or poverty or oppression or injustice. They're the ones calling out for a medic.

The job of physician sometimes involves interfacing with a cold and uncaring world on behalf of someone unable to change their circumstance, and trying to make an improvement in a system that is fundamentally flawed. If you're not prepared to roll that rock up that hill, then think about something else. Because that is what I love about my job, that I get to fight for things that mean something, even if I'm not going to win.

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.

The digital age

A while back, our EMR system went down. It happens to everyone eventually. Servers have downtime, and sooner or later, you have an outage. Sometimes it's brief, sometimes it's long, but without fail, when it occurs, the frustration is instantaneous and furious. And the old guard bemoans how terrible EMR's are, and how they cripple our ability to care. And that is ludicrous. So let's take a step back and remember the days of paper. I remember them well. There are a few wonderful events that everyone who remembers paper charts should recall, and then find themselves resigned to saying that electronic records really are better.

Handwriting is far and away the most obvious issue with paper charts. When I was in residency, there was a cardiologist with such bad handwriting that anyone who could read his handwriting was often called to interpret, whether or not they were on that patient's case or even whether or not they were in the hospital. I have uttered the words, "That loop looks like a H, so I think we should start heparin." I spent a measurable part of my day as a resident simply deciphering the terrible handwriting of other care providers.

Much more troublesome than handwriting was late charting where people would carry around their notes and then insert them into the chart later in the day, or even days later. I got into an argument with a patient before because he was convinced he saw the neurologist, but there was no note from him. Two days later, a chart note mysteriously appeared. Or nurses would chart an entire shift of vitals at the end of their shift. It was so much trouble fighting for the chart that it was just easier to chart your information some other time, and so it was often impossible to get up to date information. And that's not even accounting for paper reports, like labs or x-rays. It wasn't even worth referring to the chart for those. You'd go to the lab database or the radiology database, or if you were supremely unlucky, some poor loser sacrificed his morning by getting curbside reads on all the chest x-rays from the radiologist.

On the devious side, people would sometimes misrepresent their charting by where and how they did their notes. Some people would slip their note in several days beforehand, or date/time their notes to misrepresent when the work was done. I've seen things charted in different sections so that it would likely be ignored by medical/legal but would be safe for billing.

And then there's the missing pages that would inevitably occur, much more terrible in the outpatient setting where you might lose a note from 7 years ago that suddenly you need. However, I remember losing preliminary cardiac cath results so that we had to go down to transcription and put a rush on the dictation, since the cardiologist went home and we couldn't reach him, and needed the report to determine if we could discharge the patient.

But nothing was worse than the missing chart. I have had a student walk off with the chart to the study lounge for 2 hours and we were in full fledged hysterics. I had an intern take the chart to dictate a transfer note and the patient coded, and we had no idea what was going on or anything about the patient. I had outpatient encounters where another clinic was sitting on the chart (another doc hadn't done notes for weeks), and we sent people over to that clinic to get into a chart fight.

Sure I get frustrated with EMR systems that I've worked with. They all have their drawbacks. But thank God we don't use paper charts anymore. What absolute hell.