Monday, December 30, 2013

Humanism and Money in Medicine

“Chia buo᷈n” – Vietnamese phrase meaning “share in the sorrow”

If your time is limited, don’t read this blog post. Instead, turn directly to the second-place-winning essay in the Humanism in Medicine contest; this essay was written by David B. Duong, a third-year medical student.  In this essay, Dr. Duong – and I refer to him as “Doctor,” as this essay shows me that he already has the knowledge of the art of medicine that confers upon him that title – writes about his experience acting as the translator for a Vietnamese patient with end-stage colon cancer.  He takes us through the experience of being at the patient’s and the family’s side, as they go through the confusion and the required decision-making when the 83-year-old patriarch is in the hospital with a bowel perforation – a hole in the large intestines.  David Duong, through his caring, helps the man and the family understand the illness, understand their options, and ultimately says goodbye when the man goes home with palliative services to spend his last days with his family. 

Duong writes toward the end of the piece:

“As a final goodbye, I reach out my hand to shake his and wish him continued health and strength.  He grabs my hand and tells me, ‘Thank you for helping me not be afraid.’ … I have also learned that by caring for the patient, by placing the patient at the center of our medical practice, we can establish a trust relationship that just might lessen that fear.”

In this essay, David Duong never once mentions costs, and my bringing it into the discussion may seem to some to be crass --as though I am diluting the message of caring and trust that is inherent in this essay.  However, I see cost and care as going together.  For me, lowering costs in ways that maintain trust and relationships is critical to good care, as it improves access to care.  Unfortunately, many of our well-meaning efforts to lower costs end up diluting trust by short-changing the time and communication critical to building and maintaining needed healthcare relationships.  David’s interaction with this family saved money.  By caring for the patient and the family, and by communicating with them using their language, their values and their culture, he helped them embrace home palliative care.  This type of situation could have easily have been much different. The fearful family and patient, not trusting the doctors and nurses caring for them, could have demanded “everything” be done, causing useless pain and cost. 

In this era of 10-minute office visits, Internet-based self-service diagnosis and algorithm-driven healthcare, I still believe that the most effective way to lower costs is to have trusted health professionals at the side of people in need.  David Duong’s essay conveys that message more eloquently than I ever could.  

Thursday, December 26, 2013

Harms, Benefits and Unknowns in Surgery

“If you are a surgeon, think like an internist, and if you are an internist, act like a surgeon.”
“Never give a patient with a medical illness to the surgeons.”
                                                     Robert Whitlock, MD

When I was a medical student at the Columbia University College of Physicians and Surgeons, Dr. Robert Whitlock was an attending who inspired me to focus on gastroenterology.  Dr. Whitlock was a southerner in a prestigious New York medical school – a private practitioner who taught and believed patient care and teaching were the two noblest activities that anyone could ever take part in, and a purveyor to medical students of “Whitlock’s Rules of Medicine,” always given in a southern drawl that made them seem so much more important.  The two quotes above may not have originated with Dr. Whitlock, but they will be forever associated with him in my mind.  I thought of these rules as I read several articles in the December 26, 2013 Wall Street Journal

It is striking that in today’s premier financial newspaper, there are three articles related to healthcare -- only one of which is related to health insurance.  The other two are related to surgery – and the Wall Street Journal isn't the place where one expects to see the latest surgical studies to be published.  As is my routine, I went back to the original medical journal sources of the articles after reading the news articles.  They both make it clear that the wisdom of Dr. Whitlock holds today, just as it did back in the 1970s. 

The first article was about a study from Finland reported in the New England Journal of Medicine this week. The study used the technique of “sham surgery” to determine if people with partial meniscal tears that are not the result of acute injury, benefit from arthroscopic surgery to remove the torn part of the meniscus.  Sham surgery is surgery in which someone is taken to the operating room and put under anesthesia; a small cut is often made —and then nothing else is done.  Patients wake up thinking that they have had the surgery, but it is a fake.  Based on this study, it appears that arthroscopic surgery has no benefit for someone with a torn meniscus not due to an acute injury.  In any surgery, if there is no benefit, then there is only the risk of harm from the anesthesia and the surgery itself, and of course, the $4 billion in annual direct medical costs in the United States that make the study worthy of the Wall Street Journal.  The unknown in all of this is whether specific patients have certain characteristics that would make them likely to benefit from the surgery.  The authors of this study specifically excluded certain people (as any good study would), but in those exclusions there may be others who would benefit.  I make this point because the study does not say that all arthroscopic knee surgery is unnecessary.
Sometimes we don’t realize a surgery is harmful until the surgery has been performed for some time.  The other Wall Street Journal article focuses on a 2012 study, entitled “Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms.”  In morcellation, a uterine benign tumor is removed via hysteroscopy —which involves only a very small incision and quick recovery time –after the tumor is basically smashed into small pieces.  The problem: If the tumor is cancerous, then the small pieces can get lodged in the abdominal cavity and cause the cancerous cells to spread.  This was originally believed to be an exceedingly small potential harm, but has turned out to be more common (though still very unlikely) than previously thought.  Since the harm fits into the category of the “small probability but devastating outcome,” the procedure has come into question.

In a world of big data, my voice on this blog has been, and will continue to be, about relating studies and data to individuals in need. What does all this mean to the individual and how does that relate to the wisdom of Robert Whitlock?

  • Surgeons believe in surgery.  In order to be a surgeon, you have to believe that the work you do is effective and helps people, so that creates a bias toward operating.  My wife’s uncle was an orthopaedist.  He called himself an orthopaedist, as he believed that the term orthopaedic surgeon was too limiting -- and it pushed physicians to think that all solutions were to be found in the operating room.  If you don’t need surgery, don’t go to a surgeon.
  • If you go to a surgeon, make sure you go to one who “thinks like an internist,” meaning he or she will evaluate all the various solutions, understand the potential harms of surgery, and are willing to walk away from operating if the risk of harm is larger than the potential benefit. 
  • Be wary of the procedure that is “new” and promises to be easier for the patient.  The risks may be only partially understood and the potential harm may be greater than it appears.  When I was practicing gastroenterology and nutrition, it was popular to treat obesity by placing a balloon in the stomach to limit the amount of food that could be eaten – until the complications of the balloon perforating the stomach and esophagus became apparent. 
  • Don’t assume all surgery is unnecessary.  Some surgeries are lifesaving, and the same type of bias that may cause unnecessary surgeries can also cause people to avoid having the surgery that they need.  

A decision to have surgery should be thoughtful and made with complete information and the help of trusted family, doctors and other knowledgeable health professionals.  It should be based on the specific facts of the individual patient at that point in time informed by the medical evidence that best defines the potential benefits, harms and alternatives available.  It is never a decision to be taken lightly.  

Saturday, December 21, 2013

Don't Just Do Something Stand There

I first wrote this more than two years ago and it was directed towards the dedicated Health Assistants who work with me at Accolade.  I was asked to reprint it for them as the message still holds, especially in this holiday season when the most chronic of problems can seem to be even more insolvable. As I read it, while the message is directed towards Accolade Health Assistants, it actually is true for all of those in the caring professions.

We have developed, and continue to develop, a wonderful culture of problem solving, and of helping.  That culture is being built by every one of you as you work every day to help your clients and their families.  It is something we strive for and it is what makes us successful.  Because we are all such problem solvers, dealing with people who have problems that are not amenable to a solution, an answer, can cause us to be frustrated.  That frustration comes through to our clients and we cease to be effective.  So, the question is how to be most effective when solutions do not exist.  How do we deal with our own desire to change a bad situation when we have no control over the situation?  How do we learn to just stand there and why would we want to?

Lately, I have been discussing clients with many of you whose problems go back many years.  These problems have had numerous attempts at solutions, stops and starts in therapy, and frustrated health professionals who end up ineffective.  I do not want us to join the list of frustrated professionals, who have failed to find solutions.  The fact is that there are many problems that have no solutions. 

You cannot reverse an irreversible illness; you cannot make an anorexic eat over the telephone; you cannot explain and treat symptoms that are related to underlying causes that go deeper physically and emotionally than current knowledge can fathom.  We cannot perform the big miracles that these people need. 

However we can do a lot just by being there.  We can create small miracles that, over time, can lead to very meaningful results to the client and their family.  We can help people deal with the hand they are dealt and live with their own reality, in such a way as to enjoy and embrace their lives. 

We do all this by listening, by informing, and by accepting the client as they are.  We provide a safe person, their Health Assistant, who will hear them and will gently influence them towards attitudes and behaviors that will lead them to make better health decisions.  We will give them a trusted person who helps them when they need help and comforts them in a very human way when there is no medical science that can help them. 

When we do all this, it turns out we will create small miracles that can turn into very large results.  When we do this also, we help people make better decisions and that will save them and our customer companies money as well.  We have found out how to work miracles as we improve care and save money but the way we do it is by each and every one of us understanding our limitations and understanding the power of listening and empathy rather than trying to cure every ill.    

Monday, December 16, 2013

Healthcare as a Calling Across Generations

A young resident’s recent article in The Journal of the American Medical Association (JAMA) – as well as a more senior physician’s blog post, gives me hope that the calling of medicine lives on, and that professionalism by all those who care for others in need remains the key component in any healthcare system.   

The article by Dr. Diane Chang, entitled “Scut,” starts by defining scut work:  

“I want to talk about scut work, defined as trivial, unrewarding, tedious, dirty and disagreeable work; in other words, I want to talk about … the physical, backbreaking, day-to-day work of taking care of another person.” 

It often is not pretty to care for another human being who is sick.  It is filled with pain, and with sights and sounds that many would consider disgusting.  Dr. Chang rightly points out that the job of tending to the needs of a person are not a doctor or nurse issue, but a human issue that is the job of every person in a caring role: 

“I worked with an intern who, during her first month, took care of a 32-year-old patient with advanced HIV and intractable diarrhea.  One day my intern told me that she had, alongside the nursing aide, cleaned him up, as well as his bed and the floor. Why did you do that, I asked.  It’s not your job.  She answered that often, they did not clean him up right away and she did not want the patient to have to lie in his own excrement for a minute more than he had to. Amid writing orders and discharge summaries, relaying information from consults back to the team, and learning how to be a physician, my intern also made it her job to clean up poo.”

The intern understood that the nursing aide was, in that moment, even more important to the patient's care than the physician and the doctor's job at that point of time was to help that nursing aide.  To understand that simple fact is to have true passion for patient care.   It requires understanding that the “small” issues like cleaning up a soiled floor and bed, can be more impactful on a human scale than the “big” issues.
On the other side of the generational divide comes a blogpost entitled "Playing Doctor" from Dr. James Salwitz, an oncologist who has been in practice for more than 25 years. In that piece, he talks about the need to get past the personal issues that a physician (and this applies to all health professionals) has on any given day even if it means “playing doctor.”  Even when the passion wanes, the true professional understands the need to do whatever has to be done to help the patient. 

“However, there are times when it gets to be too much. When one is tired, the paperwork piled to the ceiling, you are missing irreplaceable personal events, then the quality of patient interactions seems to deteriorate to completing disability forms, rescheduling already delayed procedures, rethinking diagnostic ideas, salvaging failed therapies and running late in a chaos of myriad minor delays. Then it is very hard to summon the needed insight, compassion and focus which are vital to being the kind of doctor towards which each of us strives. Then, the best you can do is ‘play doctor'."

For the physician in practice for 25 years, the paperwork and the disability forms are even worse than cleaning up the poo.  But with the wisdom of experience, Dr. Salwitz understands that if you have the professionalism, you will act in the interests of the person in need. 

“Nonetheless, you are just human, so those tough moments will occur, when you cannot really ‘be a doctor’. …. On those days, you just ’do your job,’ be there for the patient and suppress the loss and weariness. Paradoxically, it is that commitment to the doctor’s role, when you are just playing, which marks the great doctors, because even on their weakest day they put the patient first and their own healing later.”

One day at an airport, after I had left practice and was a health policy consultant, an elderly woman collapsed near me in the baggage claim area. I immediately went over, checked her airway and checked for a pulse. In other words, I put my fingers in her mouth and my fingers on her neck. I then started CPR which, at that time, called for mouth-to--mouth resuscitation in addition to chest compression.  The consultant with me was impressed and said, “You really are a doctor!”  I knew I was “playing” doctor. The thoughts going through my mind, while they included a desire to help this woman, also included my own fear of infection and my own wish that I was not doing what I found myself doing. I just knew that of all the people standing there, I had the training and the calling to help this woman.

Dr. Chang and Dr. Salwitz both show caring, one with the passion of youth, and the other with the wisdom of age.  As I put together the passion of Dr. Chang and the wisdom of Dr. Salwitz, I see the wonder of medicine and the caring professions as a calling.  These two people at different points in their careers share the mission of helping those in need and thus suggest that the light of care in health will continue perhaps in spite of the politics and the policy debates.

Wednesday, December 11, 2013

Being “Certain” in an Uncertain Medical World

The art of medicine is managing uncertainty. Yet, be honest: Have you ever met a more certain group of people than physicians? As a physician, I am no different. This past week, a close friend of three of my sons called me, as he was having severe abdominal pain. I spoke to him and his wife and quickly determined he needed to go to an emergency room. I told them that while I could not diagnose over the phone and without examining him, I did think this was most likely a kidney stone attack and not appendicitis. The next morning -- when he was out of surgery for his appendicitis -- I thought about how my relative certainty about it being a kidney stone was so wrong. I actually thought about asking to see the pathology report to make sure it was really an inflamed appendix, and not a kidney stone.  I was certain even in the face of uncertainty and conflicting data. 

That incident got me thinking about another time when I was wrong in a very similar situation. At that time, more than 35 years ago, I was an intern in internal medicine and I developed severe abdominal pain. My wife -- the smartest physician I know and at that time an intern in pediatrics -- took me across the street to the emergency room where I gave a perfect story to the surgical resident for appendicitis (this was in an era before we did CT scans to rule out appendicitis), and they started to get me ready for the operating room. The surgeon, my wife and I were all positive this was an acute appendicitis, but then I gave a pre-operative urine sample that was filled with blood.  My wife and I were surprised, as was the surgeon, but we all realized that while we were certain it was appendicitis, we were wrong. It was really a kidney stone. 

Even in this day of advanced technologies, much of medicine is still mysterious, and the practice of medicine is all about understanding that diagnostics and therapeutics are based in science, but are only rarely in concrete isolated fact.  More often, there are competing facts and multiple complicating factors; physiologic, sociological and psychological -- as well as different communication styles and contextual issues that make truly good doctors understand and learn to cope with a fundamental level of uncertainty in all that they do.  Perhaps coping with that uncertainty is why physicians often seem so sure.  Perhaps that is one way people survive as physicians. 

The secret behind the physician’s bravado is that caring doctors have to also manage their own anxiety and their own uncertainty while they manage the patient. They deal with this influenced by their own communication style and their own life context. The idea of a physician being perfect is a myth, and many excellent physicians struggle internally with carrying that myth. So doctors manage this internal uncertainly in various ways. Here, I offer my own characterization of doctors’ techniques for managing the uncertainty inherent in medical care -- and their own anxiety that occurs as a result. These techniques can be very adaptive, helpful – and, at the same time, dangerous to the patient and the physician:

When most uncertain, appear most certain:  Early in my career, a very prominent leader in academic gastroenterology told me his rule for handling patients with chronic irritable bowel syndrome:  “The less specific the treatment, the more specific the instructions should be.”  He told me of prescribing tincture of opium for these patients in the 1950s and telling them to place 11 drops -- not 10 or 12 -- in one-quarter of a glass of water, not half a glass, and drink it quickly. While he knew the efficacy of the treatment he was giving was uncertain, he believed that showing certainty as a physician would make it more likely the treatment would help than if he wavered.  This maximizes a placebo effect, which is real and effective; however, in the long run, this also carries the risk of harming the patient’s trust in the physician. 

Use specialist consultants generously:  This is the other extreme of the first technique. Instead of appearing to be totally confident in all pronouncements, the physician is quick to send a person with any illness to a specialist. In my previous life as a gastroenterologist and nutritionist, I was often frustrated by consultations that appeared more related to the referring physician’s lack of knowledge than the patient’s need.  The really skilled physician knows when to use the specialists in terms of both timing and condition. A consultation made too early creates risk for the patient, as the specialist may feel the need to “do something” -- when doing nothing and waiting for a self-limited illness to run its course may minimize harm and maximize benefit for a patient. The doctor who farms everything out due to his or her own internal uncertainty does the patient no favors while the doctor who never uses specialists may create risk by delaying needed care that only a specialist can give. 

Order every test to rule out the less likely diseases:  In this case, the fear of missing a disease drives over-testing.  While the good physician is compulsive and complete, the advances in medical technology and the ability to order newer and newer tests often lead physicians to downplay the harms that can come from over-ordering.  Every test has false positives and false negatives. I have seen people saved from devastating illness from a test they didn't really need (the cancer found on a CT of the abdomen for pain that was “incidental” and not related to the pain), but I have also seen people die as a result (the person who has surgery when a finding on a similar CT scan is thought to be a tumor, and who dies during the surgery in which no mass is seen).  The risk of harm from over-testing is higher than the likelihood of benefit however if the physician treats everything as routine and not needing investigation, that too can be harmful. 

Follow the algorithm: In this era, the more we learn, the more important standards and guidelines are.  However, the doctor who only relies on the algorithm and does not “see” the person behind the disease will miss important opportunities for diagnosis and treatment.  It is often easier for physicians to take solace in following an algorithm than to understand that algorithms are limited and cannot take the place of the decisions a good physician needs to make in managing uncertainty.  Dr. Saul Weiner’s research on the context of medical care shows the need to understand the patient’s life in order to maximize the benefit of the algorithm and minimize the risk of blind obedience to it. 

Go to the academic medical studies: I usually believe that this is the most useful technique, yet the doctor who needs to look everything up is neither efficient nor maximally effective.  You need to know enough and, at the same time, know what you don’t know and what you need to investigate. You need to understand that facts change and that the latest pronouncement of a breakthrough in the medical literature may be followed by later reports showing the breakthrough to create harm as well as benefit.  At the same time, I always will trust a doctor who says “I am not sure” and “I want to look up more information” more than a doctor who tries to show he or she has mastery over everything. 

The good doctor manages uncertainty. The great doctor also effectively communicates that uncertainty to the patient while still maintaining the patient’s trust.  That is the high form of the art called medicine.  

Saturday, December 7, 2013

Ted Med Great Challenges Discussion

This week I was honored to join a distinguished group of participants in the Ted Med Great Challenges program underwritten by the Robert Wood Johnson Foundation on a panel moderated by Dr. Kavita Patel.  Here is the panel discussion (broken into two parts, due to a technical difficulty during the program).