Reflections in a Head Mirror
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2/8/2010 Outside the Comfort Zone A life spent making mistakes is not only more honorable but more useful than a life spent in doing nothing.
-GB Shaw After over twenty years working as a head and neck cancer surgeon, much of what I do has become routine. Even the operations that once kept me awake at night or the procedures that required a trip to the library are just part of a day’s work. I am certain that most vocations have the same experience. The commercial airliner pilot plans her weekend while she is constantly scanning the displays and switches arrayed around her. The construction engineer carries on unrelated conversations while aligning girders that will support giant buildings. The bus driver listens to the radio as he guides his vehicle for the hundredth time through the switchbacks and the mountain passes. Things that used to command every bit of attention no longer require that degree of intensity. Every once in a while, though, something comes along that brings everything back into a sharp-edged focus: I had performed dozens of procedures on patients with voice box cancer over the years. My experience told me that this operation would be difficult because of this particular patient’s previous radiation, but otherwise should be straightforward. What I found, though, was anything but routine. Nests of cancer cells were scattered throughout the tissues and a new separate cancer was identified. The original plan was quickly abandoned, and, while the patient lay on the table, I went to the family center to have a detailed discussion with her husband and children. I returned to the operating room and continued to work. Over the course of the day, there was another change of plans, another trip to the family center, and phone consultations with colleagues. I ended up performing a procedure about which I had only read. I re-checked everything. Several hours later than originally anticipated, we were finally finished. Sitting in the recovery room waiting for her to wake up, I realized that I was in need of some recovery as well. I had spent much of the day outside of my “comfort zone” in a place requiring my full attention, all of the insight I could muster, a bit of creativity, and reliance on others. Now, I could return to the routine of postoperative care and paperwork. Although drained, I was energized and alert. I felt alive. Happily, she did just fine, thanks to the good advice I received from my colleagues. I slept very soundly that evening.
Posted 4:35 PM 2/1/2010 Two QuestionsInsanity: Doing the same thing over and over and expecting different results.
- Albert Einstein As medical students rotating through the wards, we spent a significant portion of each day ordering laboratory tests and then chasing down the results. We wanted to investigate our patients’ illnesses and, just as importantly, we wanted to be prepared for any question with which our professors might surprise us during Attending Rounds. One day, as I was hurriedly checking boxes on a laboratory order form, my resident challenged me to justify one of the blood tests I was requesting. “You can order that test after you answer these two simple questions ...” His eyes narrowed. “First of all, what exactly are you going to do with the results? And, second, who is going to pay for it?” He became increasingly impatient while quizzing me about all of the potential outcomes. Clearly, I would need to spend my afternoon reading in the library. I also admitted that I had no idea how much the test would cost or whether the patient’s insurance would provide coverage. It turned out that this was, indeed, a very expensive blood test that was only performed in an out-of-state laboratory. The results would not be available for several days. Checking that box would have cost the patient several hundred dollars; by the time the result was available, it would have been all but meaningless. “Aha!” my resident chided me triumphantly, “Do you still want that test? You need to make an effort to understand the impact and cost of everything you order.” I had learned a lesson and sheepishly tore up the slip. My memorable medical school incident came back to me last week while reading an editorial in the New England Journal of Medicine. Dr. Howard Brody reminds us that high-cost care is not necessarily better care and that a study of regional variation recently showed that “nearly one third of health care costs could be saved without depriving any patient of beneficial care.” Cost-effective care is possible. Since physicians order tests, Brody suggests physicians need to be at the forefront to curb healthcare expenses. As a start, he proposes that each medical specialty create a “Top Five" list of its most commonly ordered, expensive tests and treatments for which there is little evidence of any meaningful benefit. The specialty would then be charged with educating its own members. In “In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.” In the best of worlds, this approach represents utilization oversight driven by providers rather than insurers or government. Resource consumption — be it money, time, supplies, or energy — is a real-life dilemma in every medical center; in medical care, there are just so many places where simple decisions carry a fiscal wallop. Three quick examples: Technology is routinely touted as providing improved safety and efficiency, but, sometimes, it adds cost without any proven benefit whatsoever. Adding one more test or ordering one more consultation at the end of a clinic visit “just to be certain” quickly adds up when repeated hundreds of times each month. And, of course, any provider who can spell “PET Scan” can order one. We can all play a role in cutting costs. I tend to avoid technology unless I can show that it is truly going to benefit a particular patient. For example, I recently saw a patient for a second opinion. His community physician had recommended an extremely expensive test. After reviewing his records, I told him that there was no reason to have the test performed. He was understandably skeptical. “Why did the other doctor think I needed it?” He frowned. “She said it would be very useful. Shouldn’t you order it anyway?” We had a long conversation. Deciding not to “do something” can be a hard sell. Even now as we engage in a national discussion about health care, it seems that the questions still come down to these two: What exactly are you going to do with the results? Who is going to pay for it? On both an individual level and as a society where we all depend on each other, these two questions are just as relevant — and difficult — today as they were when my resident made me stop and think about a box that I had checked on a laboratory slip so many years ago. ___ Reference: Brody H, “Medicine’s Ethical Responsibility for Health Care Reform – The Top Five List,” N Engl J Med 2010 (Jan 28); 362:283-285 (NEJM.org 10.1056/NEJMp0911423). Posted 1:25 PM 1/7/2010 The Doctor Will Friend You Now ...
The argument that you need the "laying on of hands" to practice medicine is an old and tired argument that simply has no credibility …
- Rashid Bashshur, PhD, Director of the University of Michigan Telemedicine Center
The family legend goes like this: When my grandfather’s tonsils became infected yet again, the doctor rode out to the farm in his horse-drawn carriage toting his surgical instrument set. While he was there, the doctor supposedly looked at my dad, who was about 7 years old.
"Does Ray complain of sore throats, too?" the doctor wanted to know.
"Sometimes."
"Well, put him up here on the dining room table. Let’s take his tonsils out right now, too!" And so they did.
In the days of my dad’s childhood, medical care was routinely delivered in the home.
For better or worse, the focus of medicine may well return to the home. Consider this scenario: Bob has a headache, sore throat, and a runny nose. He walks into his kitchen and sits down at his computer.
Type, type, type, type. Click. Enter. [wait] Fill in name and personal information. [wait] Enter credit card information. Enter. [wait] Screen pops up. Smiling doctor appears.
"This is Dr. Johnson! Are you Bob? How can I help you?"
Bob pulls his bathrobe tighter around his shoulders and concentrates on his keyboard. The blue light next to the camera on his laptop blinks on. "I’m sick, Dr. Johnson. I hope you can give me something to make me feel better."
Dr. Johnson peers at the image of Bob on his monitor and sets to work trying to figure out if the symptoms represent a cold or something more ominous. Over the next few minutes, Dr. Johnson makes a diagnosis, comes up with a treatment plan, and generates a bill. They both sign off. A few minutes later, Dr. Johnson opens a video chat with a different patient. The two of them could be in the same town or separated by a thousand miles.
Quick and efficient! Germ-free! No parking hassles!
A recent article describes the future of telemedicine and how, in Texas, it is already a reality. For $40, an internet company offers Texans 10-minute live video medical evaluations. The company’s Web site notes that "while sometimes there is no substitute for an in-person visit, [the clinic] offers you a convenient complement to a traditional practice." I suspect that, for a lot of ailments, a quick discussion with a prescription might be perfectly suited to a live video chat.
Where could this all lead? Perhaps, new iPhone applications will take vital signs, peer into eyes, check blood sugars, and buzz disapprovingly when we walk into fast food restaurants. Guitar Hero will spin off Surgery Hero. Digital cameras will tour our intestines in the privacy of our own homes. On-screen instructions will tell us where to place the Wii controller while we bend over and cough. Web-based interface systems will control common kitchen appliances and power tools that allow surgeons to remotely perform delicate operations.
Traditional face-to-face office visits — flesh-on-flesh — are challenging enough. They are fraught with the nightmare of overlooked signs of disease, delayed diagnoses, incomplete evaluations, and misunderstood instructions. Sometimes, words spoken in the hallway after the visit are as important to making a diagnosis as what transpires in the room. To my old-school thinking, I have enough trouble coming up with treatment plans when I have the opportunity to sit side-by-side with my patients and touch them physically. It would seem that the benefits and risks of the office visit would only be magnified in a virtual clinic.
Medical care during my dad’s childhood days was not perfect. Did he need his tonsils out? Probably not! However, there was inherent value in receiving all of his health care on the farm from the family doctor.
Perhaps the day of that "in home" approach is returning. It seems so odd to me, though, that in an era when we value both "high tech" and "high touch" medical care, that our physician-patient interactions might actually be receding to a place where we see each other only behind a computer screen and feel each other only through a keyboard. Somehow, I think, Bob and all of our future patients deserve better.
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The following is feedback received for this blog:
I agree patients deserve better! And you deliver!
- Marilyn Hagerman
right on, scribbler b! nicely written argument for the importance of in-person healing. my psychological training supervisor, back in the day, told the story of a home visit by his g.p. (in ireland!) who walked into the ill child's bedroom and announced "it smells of rheumatic fever here!" i don't think you can do that via telemedicine.
- RICHARD HOLLOWAY
www.theemptysuits.com | Posted 11:20 AM 12/31/2009 Another Auld Lang SyneAnd there's a hand my trusty friend!
And give us a hand o' thine!
And we'll take a right good-will draught,
for auld lang syne.
-Robert Burns
It was the very last night of a difficult two-month rotation early in my residency. I was On Call. Exhausted. Burned out. Going-through-the-motions. Not having a good time.
I was sitting at the intensive care unit console writing notes in the charts of two of the patients I was following.
One young woman had taken a fistful of pills and then hanged herself. Her beleaguered family had tried very hard to help her over the years and now they were spending their holidays in the hospital standing vigil at her bedside. After this one final attempt to kill herself, the family hoped she might bring light to someone else’s life with an organ donation. My task was to keep her alive long enough for her body to clear the toxic levels of the medications she had ingested. I flipped through her chart and wrote my note. Family members walked numbly past me.
In another bed lay a young mother who had been getting ready to go out for a New Year’s Eve dinner party. Her husband found her unconscious in the bathroom after having heard her collapse. After being rushed to the hospital, the scans confirmed that she had experienced a massive, certainly fatal brain hemorrhage. She was completely unresponsive and spiraling downhill rapidly. The family, dressed for an evening out, sat disconsolately at her bedside. I dutifully recorded my findings in her chart.
As I sat writing, a song came on a radio nearby. I never really knew the lyrics but I recognized Dan Fogelberg’s voice. The song is a first-person account of running into an old friend.
We drank a toast to innocence
We drank a toast to now
And tried to reach beyond the emptiness
But neither one knew how.
We drank a toast to innocence
We drank a toast to time
Reliving in our eloquence
Another 'auld lang syne'...
Then the strains of “Auld Lang Syne” filled the air. I checked my watch. It was midnight. I put down my pen and called home, wanting to talk to Kathi.
“Hi, sweetie,” I said. “Did I wake you?”
She had been dozing. “Guess so. Hi, yourself. How are things going?”
I scanned the patients in front of me. I looked at the family members moving in and out of the rooms. I looked down at the chart notes I had written. I thought for a second.
“Not well. It has been quite a day. I love you.”
“Love you, too. See you in a few hours?”
“Yeah. Can’t wait to get home. Happy New Year.”
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The following is feedback received for this blog:
As always, a well-written post. Thanks again for sharing!
- Jen
This story really hit home as I am dating someone who works in an ICU. There have recently been a couple rough nights after which he has had to emotionally unload in order to get past things.
I have had the unfortunate experience of having to sit two torturous nights in the same ICU prior to losing my (late) husband. I am proud to call him an organ donor.
Luckily, even though my sweetheart worked this past new years eve, it was a quiet night and was able to leave at 3:00am instead of 7:00am.
We appreciated the cherished time together. I know the value of quality time.
- Karen Farra | Posted 1:02 PM
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