Monday, May 27, 2013

The Bystander Effect Revisited

My son’s experience with his recent illness (and he is improving) made me go back to read a perspective article in the New England Journal published in January.  Entitled, “The Bystander Effect in Medical Care” the article retold the story of Kitty Genovese who, in 1964, was brutally murdered while 38 witnesses either saw the attack or heard the victim’s screams.  Following this tragedy, much research went into studying the “bystander effect” which was described as the human tendency to be less likely to help when other people are present.  Those studies found that the diffusion of responsibility is a major element of the effect.  If a large group of people are involved in a process, any one person will assume that the responsibility belongs to someone else or they will assume that action has already been taken.  If you think about this in less urgent matters, you can see this effect when a power outage affects a neighborhood.  Who calls the power company and who assumes that since the entire neighborhood is affected, someone else will call?  That is a common example of the “bystander effect” at work. 

The authors of this article related this effect to limits on resident work hours, the increase in subspecialty care, and the large number of health professionals involved in a patient’s care when they are hospitalized leading to a lack of coordination of care and lack of ownership any one doctor feels for a patient.  I would add in the role of the hospitalist which while potentially improving the quality of hospital care removes the primary care physician from the team.  It is the primary physician who will need to help the person through the transitions from the hospital and back to full health.  They point out the important question that is often not answered, and was not answered in my son’s hospitalization, “Who is my doctor?”  I have to add a question, that being “Who is my patient?”  All too often a contributing factor to the bystander effect is that many doctors see each patient as a disease or the “person in room 225”.    The authors of the article noted that “research also suggest that bystanders are far more likely to intervene when they are friends with one another” and then make the argument that the health professionals have to talk more and integrate more to empower more decision-making.  In other words they need to be friends with each other.  They leave out the crucial aspect of seeing the patient as your friend: seeing the patient as a person in need rather than a grouping of symptoms or a diagnostic dilemma.  Teamwork is great but knowing that Mrs. Smith who is now in the bed in front of you, spent twenty years teaching and had three children and five grandchildren and was seen as a rock to all those who knew her may be much more important.  I suspect that if any of those 38 people who heard the screams of Kitty Genovese knew her personally, they would have been much more likely to act in her defense. 

Dr. Kent Bream in a letter to the editor published in April reacting to the January article wrote that the standards and rules that we now pay strict attention to, while certainly improving care in  many ways, also “ensure a polite, rote production of services” and that “our profession should lead us to favor patients over production”. 

In medicine we are often in the business of finding and treating the uncommon event that can be catastrophic.  That can lead to inefficient production of services.  Health care is only effective (even if potentially less efficient) when we take ownership of the person who sits before us in need.  It is always about the person and not only the pathology.  Understanding the unique needs of the individual and addressing those needs as we would for a friend is a key to proper care.  That prevents the bystander effect. 

I learned that lesson many years ago.  As an intern in Chicago, I was in the Cardiac Care Unit and a writer from Chicago Magazine was there and wrote a piece about the work of that unit.  When it came out, a boxed story told of my caring for a 90 year old man in the unit who was unconscious.  I was quoted as telling the writer that the history was that this man had been sharp and active until the day before this event and was active in his community and with his family.  Therefore the idea of doing less for him than for a younger person was just not right.  I am proud as I look back on that that I knew the person and not just the situation of a 90 year old unconscious man in a cardiac unit and that I, even though I was just an intern, took ownership for the care of that person. 

So this is my call to arms.  Medical professionals and all health care professionals cannot be cogs in a machine.  We cannot be bystanders.  We must be the “friends” to our patients and take action when action is needed rather than assume someone else will do it.  

Monday, May 20, 2013

Lessons Learned at an Academic Medical Center

This past week my child got sick.  It does not matter that he is an adult, on his own, and very capable of caring for himself, he is still my child.  On a Saturday night, he called me and my wife to ask our advice.  He was having vomiting and severe abdominal pain and my old clinical roots in gastroenterology came to the forefront.  “Is the pain radiating? Are you having diarrhea or constipation? What does the vomitus look like?”  After a relatively short time it was clear that this needed hands on evaluation quickly as I suspected that he may need urgent intervention.  I suggested he go to the emergency room.  He lives near an academic medical center and he went there.  In the ER, the triage nurse saw him and determined that he needed to be seen quickly and she sent him back into a room to be seen.  There he sat for more than an hour, writhing in pain with an occasional visit by a nurse to “check on him”.  He and I were communicating via text and by phone and I was trying to stay calm. 

I finally called the ER and asked to speak to the charge nurse.  I asked her why he had not been seen and she proceeded to tell me about all the other, more important issues they were dealing with.  I replied that I understood however with a possible acute abdomen, the protocols are pretty clear: an exam of the abdomen, a CBC to check the white count, an abdominal film and upright to look for free air.  Surely a doctor could examine his abdomen and those immediate tests could be done?  She replied that the tests could only be ordered after he was seen by a doctor and the doctors were too busy. My next call was to the nursing supervisor on call for the hospital.  I explained that I did not understand how someone sick enough to be triaged into a room immediately was not sick enough to have an evaluation begun.  She said she would call me back.  In half an hour she did telling me that the tests I asked about had been ordered along with a CT of the abdomen with contrast.  I spoke to my son who said a doctor had come in to say hello but no one had yet laid a hand on his abdomen, perhaps the most important diagnostic test of all.  
After 7 hours in the ER, he was admitted without a diagnosis but with pain severe enough to warrant intravenous morphine.  The ER doctor called and spoke to me at about 3 AM and told me that the   gastroenterology fellow had been notified and would see my son in the morning. 

The next day, my son was no better.  It was about 11 AM and he still had not been seen by the gastroenterologist so I called and paged the GI fellow.  I did get to speak to him and he told me that the floor staff had told him that the admission had been inappropriate and my son did not need to be in the hospital and that he was not planning to see my son.  I asked him why my son was on morphine for pain if he did not need to be in the hospital.  Those two facts were inconsistent. He went to see my son.  I went to get a flight to be at my son’s side.  It was clear at that point that he needed a bodyguard, an advocate, at his bedside. 
That evening, when I arrived, my son was in excruciating pain, only relieved by the morphine he was receiving.  I immediately sent an email to the Dean of the Medical School, who is an acknowledged expert on quality of care, to question the quality of care that my son was receiving.  The house staff had decided that he was an "inappropriate admission", either lying, drug seeking, or just someone who was, in the great tradition of medical house staff everywhere, a “crock”.    An hour later the chief of medicine was seeing my son.  His history and physical, consistent with a senior physician overseeing residents and interns, was more thorough than any my son had received since admission.  Usually it is the other way around.   The interns and the residents spend the most time with the patient.  Meanwhile I was trying to figure out who the doctor responsible for my son was.  Between weekend shifts, night floats and hospitalists there appeared to be no one truly taking responsibility for my son’s care.  I learned that the "attending" was a hospitalist who had not examined my son at all.  Nurses stopped in occasionally but were mainly present at their monitors at the nursing stations and as disembodied voices when you pressed a button.  Suddenly, my son developed massive hives all over his body leading to his eyes being swollen shut.  I took pictures with my phone and the night float doctor finally arrived, looking a bit frightened at seeing my son evolve so quickly.  He treated him appropriately and the rest of the night was calm. 
The next morning I waited for the rounds.  I thought I would see real deep discussion and thought about my son’s troubling acute illness.  Usually rounds are first thing in the morning and involve a senior doctor, the attending teaching the residents, interns and students all about the diagnosis and treatment of patients.  It traditionally is done first thing in the morning so the plans for the day can proceed seamlessly.  I waited and waited and, while a nice young resident came in and introduced herself about 10 AM, she did not examine my son.  I asked her about the episode the previous evening and she minimized it, until I showed her the pictures which seemed to surprise and perhaps even shock her.  She said that his liver function tests had been elevating and that he was going to have an endoscopy that morning.  My son’s pain had decreased a bit and had localized to over his liver  but his nausea, profound weakness and his joint pain were still troubling.  He no longer required the morphine but was still in a great deal of pain.  I walked out to the nursing station and discovered where rounds were really taking place.  Doctors of all stripes were standing around the computer terminals.   Apparently the computer was the important patient being treated here, not the patient!  The laying of hands on the patient, the communication art of medicine, was just not deemed important.  It hearkened back to an old joke when I was a fellow in the Harvard teaching system that our goal was not cure, but dying a Harvard Death – a death with perfect lab values.    Now it seemed that the new goal was not just perfect lab values but a perfect Electronic Medical Record. 

By now it was noon, the morning endoscopy had not yet happened, my son was being kept NPO (nothing by mouth) and he had not been seen by the attending physician in gastroenterology or the attending physician who was responsible for his care.  I asked again if the nurse could please call down to the endoscopy unit and ask how many cases were ahead of my son.  The nurse called and was told that they were on their way to pick him up.  One hour later they had not yet arrived and I asked again.  They told me that patient transport had to prioritize and my son was not a priority.

They finally took him to endoscopy and the staff prepared him. Another hour passed sitting in the endoscopy unit, not yet in the exam room.  Again I asked about the delay and they said that he was next.  He still had not seen the gastroenterologist.  They eventually took him back to the endoscopy room.   I went with him.  The nurse politely asked me to leave and I politely said that I would not leave.  She brought in the head nurse of the unit who told me that I had to leave.  I explained that I was a gastroenterologist and that my son had not even seen the attending who would be doing the procedure so I would not leave.  She told me that that was against policy.  I asked her to show me the policy in writing and explain the reasoning behind it.  She left.  Shortly thereafter, the chief of medicine, a nice man and obviously a caring physician who was obviously charged with “handling” me came running in (he was already late for something he had to attend) and told me that he had prevented the hospital lawyer from coming in and that he would need to cancel the procedure and that I had caused havoc in the entire medical center.  I calmly said that I was aware that I had asked uncomfortable questions however from a quality of care point of view, I had concerns and also did not know if the endoscopy was indicated or not since he had not been seen by the gastroenterologist.  I told him that I believed the failure to evaluate my son before the procedure to be a breach of quality of care.  He told me to wait a minute and then came running back in with the gastroenterology attending who apologized for not seeing my son and explained that my son’s liver tests had been going up steadily and that it looked most consistent with an acute hepatitis of some sort but that an endoscopy should be done to rule out an ulcer as a cause.   After a brief discussion and my satisfaction that he would not harm my son during the procedure, I left.   

After the endoscopy, which did not find any pathology to explain the pain, the gastroenterologist came out and said that he thought that this was an acute Hepatitis A probably from infected shellfish.   He said that he would discharge my son from the hospital and see him in two days to draw more bloods and to go over the results of the blood tests drawn in the hospital.  That was at 3 PM.  After another long wait for transport, he went back to the room.  By 4 PM, he still had his IV in and had not yet received discharge instructions, the appointment for two days later and his prescriptions. The attending doctor of record, who was a hospitalist, came in to tell my son about the discharge.  She had never examined him during his hospital stay but was the doctor of record “caring” for him.  She left and after another fifteen minutes, I went out to see the nurse, sitting at the computer terminal, who told me that he was working on the discharge.  By 5, I left to catch my plane, after helping my son get dressed with the IV still in.   Shortly after I left, he finally was discharged.  He went to his home, still feeling quite sick, but no longer having the severe pain that had led him to the hospital.  

Two days later, he went back to see the gastroenterologist, who is also a liver specialist, and was told that all his tests had been negative including the test for Hepatitis A but his liver was still showing signs of inflammation with the liver tests being even more elevated.  That, of course, was after waiting an hour past the appointment time to be seen.  The doctor told my son to come back in a couple of weeks for more blood tests and to see him in a month and that he may need a liver biopsy. 

My son still has persistent pain and nausea and it is hard to predict his course without a diagnosis for the injury to his liver.   At the appointment with the gastroenterologist, my son asked for copies of his records so he could discuss, at length, the test results with me and my wife.  The office staff said that they were too busy to make copies. 

That afternoon, I was left to again email the chief of medicine to ask him to put me in touch with the gastroenterologist to obtain the lab tests.  He said that he would forward my email and that the doctor would get back in touch with me quickly.  It has been two days, and it is now the weekend and I have yet to hear from that doctor or see a single lab test result. 

So now my son is faced with inflammation to his liver of unknown cause and of unknown future course.  At the same time, he also processes the lessons he has learned from his interface with the best minds at this academic medical center.   What are those lessons?

  • His pain is unimportant.  His pain was discounted again and again by the doctors and nurses
  • His time is unimportant.  He was made to wait over and over again, even when he went back as an outpatient, because he was never the high priority and the doctors’ time was deemed more important than his.
  • He is assumed to be lying if the “tests” don’t show something definitive.  Until his liver tests went up and the massive hives broke out, he was assumed to be lying, faking, drug seeking or just plain malingering.
  • Talking to him, examining him, understanding him as a person and understanding his knowledge and his values is just not important.  Looking at the lab values and reports in the computer and filling in the boxes on the computer screen are important. 
  • Feeding him is not important but feeding the computer is crucial.
  • His medical records are not his own.  Giving him his records may be a legal requirement but they don’t have to make it easy or quick.  

Are these the lessons we want patients to learn?  Is this what we are teaching our young physicians?

Wednesday, May 8, 2013

Healer or Master Mechanic: The Future of the Servant Leader Physician

I will be giving Grand Rounds on health reform to an academic department of Obstetrics and Gynecology at a major teaching hospital next week.  The audience will include young physicians in training, eager to learn their new craft and excited about the skills they are developing.  I prepare my slides on the new laws and the forces that now face every practicing doctor and have to wonder whether those young physicians will be trained to be master mechanics of the human body, or holistic physicians treating all aspects of a person.  Will they be leaders of medicine or technical experts of pathophysiology?  For people in the field of Obstetrics, will they see helping a woman bring a new life into this world as a lofty endeavor that is a privilege, or just see the technical difficulties of the high risk pregnancy and the challenging delivery?  Will they be artists, scientists or the traditional combination of both that makes medicine a calling as well as a career. 

In health policy articles, doctors are often described more as expensive resources that must be carefully managed so that they stay focused on diagnosing and treating patients while maintaining productivity than as holistic healers.  Systems to prevent them from straying too far from normative algorithms rather than staying true to the science of evidence based guidelines are described as critical to good care. In that framework, the best physician is one who follows the scientific guidelines most carefully and accurately.   But evidence based guidelines alone do not reflect the context of a patient who may have family problems, financial difficulties and emotional issues that impact the diagnosis and treatment that is the core of the art of medical practice.  Will the guidelines and productivity measures allow young doctors coming up through the system to take the time to get to know their patients in such a way so they understand that context and that person who has the disease (or the pregnancy in the case of Obstetrics)? Will the new career of medicine allow the artistry of medicine to flourish while still maintaining the strong foundation in science? 

The current model for health care is also a team model.  That change from the solitary general practitioner is a strong positive however the risk of a team is that sometimes no one professional takes ownership of the entire patient and the entire situation.  There is no leader.  When we deal in a world of doctors as purely diagnostic and therapeutic specialists we risk the physician focusing on the pathophysiology of the disease and forgetting the entire person in which it resides.  The traditional doctor’s role as the leader of a team falls to the wayside.  The diffusion of the ownership of a relationship can leave a patient feeling abandoned by a complex system that only seems to acknowledge the “science” while letting the whole person fend for his or herself.  The art of getting to know a patient and their family so that the therapy can become a true partnership and a true healing is at risk of being lost. 

There is also an emphasis on a patient’s participation in their own care.  This is also a strong positive as good care should be a partnership.  However much of the writing on patient participation is focused on the patient’s access to Internet based tools and apps and is more about “self-service” medicine than it is about partnership with their health professionals. 

What will I tell these young physicians who are starting their careers and their lives as physicians?  I have to tell them of the challenges ahead.  The challenge of taking time to get to know your patients when you are an expensive resource and you will be judged on your productivity.  The challenge of honing the skills you will need in order to interact with patients as people and not only collections of symptoms.  Those are skills to be learned and practiced over years.  That is why medical training is a hands-on mentoring model that gradually allows the resident in training to take on responsibility in small pieces as they develop those skills.  The skills are not only intellectual but interactive.  Just how do you tell a new mother that the child she has just delivered, following the totally normal pregnancy, has a genetic illness that will eliminate the possibility of watching that child grow to independence?  How does a resident learn to diagnose and treat and also learn how to stay with a person as they are leaving this life with a terminal illness?  On a more mundane level, how does that doctor, or nurse practitioner, help the person with a “minor” self-limited illness who is frightened and struggling to get through the day, convinced that the illness is more significant and more life threatening than the science reveals it to be?  How do we, as a nation, encourage this art through our health policies and teach this art to young physicians and other young health professionals?  How do we teach them the privilege that we have in helping people on a daily basis, using the communication, empathy, and caring arts that we have learned from those who taught us as well as the science that we now focus on in our education?

Traditionally, doctors and other health professionals were trained to be “servant-leaders” and the history of medicine began with a religious framework.  In my religion, Judaism, Maimonides, one of the greatest Jewish thinkers, was a physician and a healer and his code of medical ethics, written in the 12th century is still used today.  One line of the oath says, "May I never see in the patient anything but a fellow creature in pain."  In Christianity Jesus is traditionally seen as a healer. In Islam, Ishāq ibn ʻAlī al-Ruhāwī wrote in the 9th century, that physicians must be "guardians of souls and bodies".

The concept of the servant healer which was described in our current era by Robert Greenleaf in 1970 in his landmark essay “The Servant as Leader” is based on religious and philosophical thought.  That concept has been embraced and developed even more by Christian writers who have described Jesus as the model for servant leadership. 

Greenleaf wrote,

"The servant-leader is servant first... Becoming a servant-leader begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first... The difference manifests itself in the care taken by the servant first to make sure that other people's highest priority needs are being served. The best test, and the most difficult to administer, is this: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?"

 Medical training used to stress living with patients, and learning their lives and their experiences in order to better understand what they are going through so as to be a better servant.  Go into any old, established medical center that was founded in the early 1900s and you will see lists of names of doctors and nurses who died from infectious diseases as they fearlessly took care of their patients while living with them in the hospital.  Those people were trained to be servants, artists, and yes even spiritual guides through an illness.  They were taught to be leaders in the best tradition of servant leaders.  Has the arrogance of science removed some of the caring and serving that characterized medicine in the past? 

In the Talmud, in Judaism, there is a passage that says, “The best of the doctors are bound for gehinom (hell)”.   This is baffling however Dr. Daniel Eisenberg of Thomas Jefferson University School of Medicine gives two interpretations.  One explanation is that the physician is always at risk to make a preventable error that would result in death or injury giving them criminal responsibility.  The second explanation is that the physician must be humble and the doctor who sees himself or herself as the “best” may not recognize the need to see himself as an intermediary and a partner in healing rather than the source of healing.  This too, will lead to “gehonim”.

At these Grand Rounds, I need to communicate the choices they will have.  Will they be healers or master mechanics?  Will they take time with patients or be “productive” in diagnosing and treating?  Will they be teammates focusing on their narrow area or servant leaders?  I pose these questions and hope to challenge them to be the servant-leaders, the healers, to continue in the ancient tradition of our craft. How they answer those questions will be up to them.