Monday, June 29, 2015

My Recent Hospital Stay and the Care of the Computer

This did happen but should not be seen as disparaging the nurses and doctors who were responsible for my care.  They performed my procedure efficiently and skillfully.  Those health professionals are just working in a healthcare system undergoing dramatic change legislatively, financially, technically and even socially.  That is difficult for all concerned – doctors, nurses, and patients.  As we proceed with these changes, and with making better use of computer systems and electronic media in medicine, we must never lose the human aspects of caring. 

I was recently discharged from the hospital after suffering an acute problem that required an invasive procedure. For those of you worried about depersonalization of medical and nursing care I want to reassure you.  The commitment to caring for the computer is front and center.  The nurse and the doctor are diligent in paying attention to the computer, frequently touching the computer to show concern, and feeding it frequently.  But it is not only the computer being cared for.  The checklists are all being filled in.  The population health data repository is being enriched whether or not the data is accurate or needed for the individual patient care.  That makes the regulators and the health policy experts (and admittedly I may be considered to be one) happy.  That means that we will have data to study, and to ponder and to drive new regulations and policies.  I am excited to know that the databases that are produced by the questions that are asked will be robust. 

As the patient, I felt better as the nurse sat across the room from me in front of the computer terminal, asking me questions that sometimes had little relationship to me or the reason that I was in the hospital.  It was good for the population health database.  The bright, young nurse had been well trained and touched the computer frequently to show her concern.  When something had to be done that required touching me, the patient, she carefully, and with great concern, called in the nurse’s aide to do such tasks such as take my vital signs so that her concentration on the computer checklist was not diverted.  That also allowed for the principle of practicing at the top of your license to be fulfilled.  I felt happy and secure that all documentation was in order and that all procedures were followed to the letter.  I knew that she was helping the hospital capture all the needed information for payment and that the system would be better for the reimbursement being done properly.  I knew that the Joint Commission, which accredits hospitals, would give this particular hospital a high mark for having followed process and documented in a rigorous way. When she asked me, as it was the next question on the list, what my goal was for the day, and I told her that it was to survive until the next day, she dutifully recorded it and even got up from the computer terminal to write it on the whiteboard for all to see. 

When it came time to prep me for the procedure, which required washing and shaving certain areas of my body that were to be the focus of the procedure, she carefully and thoughtfully again called the nurse’s aide to get that done. The nurse’s aide asked me in turn if I would do it myself and even if I had a razor as they had moved floors and could not find it on that floor.  Her concern for my sensitivity at being touched was striking and the annoyance that she showed as I told her that I would rather that she prepped me was only to show her concern for invading my space.  The entire time, I knew that the nurse was at the monitoring station in the center of the floor and was able to watch for any abnormalities of my heart.  I felt safe and cared for.  When the monitor alarms went off and no one came, I could just push the buttons and I knew the caring voice of a nurse would be projected into my room saying soothingly, “can I help you?” in order to make me feel as though she was in the room with me.  That was always followed by a message that she would get someone into my room as soon as they were available.  It made me feel less afraid.

The entire time I never did see my doctor, except at the time of the procedure, however I knew that he could access the electronic medical record from anywhere in order to make his day and night more efficient.  I felt good knowing that he really did not have to see me or talk to me at all but that he was in charge and on top of all of my care.  I knew that having him say hello before I was sedated was enough to have trust that all of my concerns and fears were being addressed. 

So be reassured: Caring for the computer, filling the database, and driving efficiency remains the focus of medical care today.  As a patient, that should make you all sleep well at night.  

Tuesday, June 9, 2015

The Gift

Last week I had the privilege of spending a day with a group of physicians who transcend the science of medicine and are true practitioners of the healing arts.  They are people who recognize that the role of health care goes beyond the treatment of disease and is about the healing of people beyond the disease they present with.  The Accolade Medical Advisory Board consists of Dr. Larry Kaiser, Dr. Saul Wiener, Dr. Ivor Horn, Dr. Adam Perlman, Dr. Samuel Hammerman, Dr. Andrew Lasher and Dr. Joe Betancourt and they were together for a discussion of ways patient care can be improved and ways Accolade can continue to contribute to that improvement.  They are all leaders in medicine and their biographies can be found here.  The day was exciting because it focused on ways to improve the care of people in ways that address the differences in people rather than the commonality of disease.  The discussion concerned a person’s life and experience with the healthcare system.  Most exciting was the consensus that this humanistic approach to medicine holds within it the key to the dual goals of improving the quality of medical care and lowering costs in order to make care more accessible.  All of these leading physicians have the gift. 

So just what is the gift? The ability to internalize that the trust given you by your patients is sacred. This means seeing each patient as a unique person, one with their own life, their own reactions to disease, and their own values. Indeed it means seeing not 'patients' but people: professors, shopkeepers, clergy, salesmen, fathers, grandmothers, all as complex individuals with their own worlds of families and friends who they love and who love them. An older patient who, on the surface, presents as weak and confused, must be seen back to his younger self, as one who has lived a full life of many experiences. A young adult struggling with chronic liver disease must be seen as a person on the cusp of a career, a family, and hope for a full life. All doctors are trained to see pathologies. The best doctors, the ones with the gift, are trained to see the human beings behind those pathologies: people struggling to rise above the challenges of life, including those who sometimes succumb to those challenges. Each physician who has this gift had wonderful teachers who passed this gift on to them.

During my years of training, the clinical professors who gave their time for the pure love of medicine and of patients were the core of teaching how to relate to patients and understand them as people. It is a difficult gift to learn.  Dr. Shunichi Nakagawa in the journal JAMA Internal Medicine talks about going from being a surgeon to a specialist in palliative care.   He found it was even more difficult to learn the communication skills than it was to learn surgical skills.  “Although a conversation looked so easy and seemed so logical when my mentor started it, when I tried for myself, I became stuck at each step – the exact same feeling I had had during surgery.  What is the difference?  How could I get better? How could I be like him?  My time was limited; the palliative care fellowship lasts only a year.”  It was and is difficult to maintain that gift as well because the emotional toll can easily lead physicians and nurses to focus more on the mechanics of disease rather than risk internalizing the emotional trauma that they feel with their patients.  I had a conversation recently with Dr. Chip Rice, a nationally known expert in intensive care and currently the President of the Uniformed Services University of the Armed Forces.  He said that there are very few grey heads working in the Intensive Care Unit.  All of the doctors tend to be young because the trauma of dealing with so many people who are critically ill and who die, can lead one to leave that environment.  Those who stay can suffer the risk of focusing only on the mechanics of the unit, the ventilators, the perfusion drips, the computers, and the like and lose the humanity.  In his just published book, “On the Move”, Dr. Oliver Sacks speaks movingly of this gift.  He states, “I felt it my business, my responsibility, to enquire about every aspect of their lives.”  He speaks of one of his teachers who “taught me about paying attention listening to what lies beyond the consciousness of words.” 

I started the meeting of our Medical Advisory Board meeting this past week with those words from Dr. Sacks because they spoke to the shared beliefs of those people who sat around the conference table.  While I sometimes worry that the gift is at risk of being lost in a medical world of doctors focusing on the computer and the app rather than the patient, the people at that table who discussed the importance of a person’s culture, the importance of their life context, and the effect that socioeconomic status has on health care reminded me that the great teachers still exist.    With people like Chip Rice teaching our military physicians, and people like Larry Kaiser at Temple Medical School, Joe Betancourt at Harvard, Ivor Horn at the University of Washington, and Saul Wiener at the University of Illinois teaching medical students across the country, I know that despite our movement towards potentially impersonal computerized care, the clinicians are still teaching the humanity of caring for others along with the pathophysiology of disease.  They are staying true to the Oath of Maimonides, an oath now recited by the graduates of many medical schools which states, “May I never see in the patient anything but a fellow creature in pain.”  The next generation of physicians has a very difficult medical world ahead of them as we go through a computer revolution in healthcare and an ongoing political firestorm however they still have the great teachers and role models and that does reassure me.