Rip Van Doctor

Cindy Fenton is one of the best doctors I know, a superb clinician-educator who was directing the UCSF Department of Medicine’s educational programs when, in 2001, she stepped off the academic treadmill to raise her three children. With her youngest now in first grade, I recently managed to coax her back into clinical medicine. In early January she spent two weeks as an attending physician on the general medicine service at UCSF Medical Center, after a decade’s absence.

I asked Cindy for her observations, knowing that they’d be astute – and that sometimes the best way to truly see something is to step away from it, then view it again through fresh eyes. Some excerpts from her note to me are in italics (with irrelevant clinical facts changed to please the HIPAA gods); my comments follow:

The patients seemed sicker, the service busier, the residents’ abilities at about the same high level. There were far fewer “private” type admissions than I remember previously – mostly pulmonary transplant patients and some private GI patients. Even on these patients, the subspecialty attendings welcomed the medicine team’s input, so the dynamic seemed more positive.

The phenomenon of sicker patients in the hospital is well known. With the remarkable things that can now be done in the outpatient world, the admission threshold is far higher than it was a decade ago. But on a modern academic teaching service, this trend is turbocharged – it’s like we’ve centrifuged a sample, poured off the supernatant, then concentrated the remaining solid core several more times.

First, many community hospitals have lost (or “lost”) the capacity to manage patients with highly specialized conditions, particularly those with no insurance or Medicaid (“we just don’t have GI coverage over the weekends”). Such patients often end up at academic medical centers (AMCs), the providers of last resort.

Next, at every AMC, housestaff duty hour restrictions have led to the creation of non-teaching services run by hospitalists. While some of these services manage a randomly selected group of all medicine admissions, many – including ours – preferentially siphon off patients who are less complex, leaving the teaching service as an enriched sample of the very, very sick. In our case, this phenomenon is accentuated because we’ve based our non-teaching service at Mt. Zion, a nearby small hospital owned and operated by UCSF, which has less access to specialized and intensive care. This tendency to move bread and butter patients out of Mecca to outlying hospitals that can manage them less expensively is only going to grow as cost pressures on AMCs escalate (more on this in a coming blog).

These trends have collectively turned many AMCs into huge intensive care units, places where patients have pneumonia, yes, but it’s pneumonia on top of their lupus, their immunosuppressives, and their cardiomyopathy. This raises the question of whether the AMC’s inpatient service remains the best place to train the next generation of doctors. Our medicine service is a wonderful, vibrant place and I am convinced that the housestaff and students learn lots of useful things there. But it is increasingly not a place where they learn how to take care of the regular stuff they’ll see in a community practice. (Luckily, our housestaff also rotate through a VA and a county hospital, so they see a diverse population overall; my concerns would be greater if their entire inpatient training was at the AMC.) Over time, we’ll need to rethink where our trainees go to get their clinical experience.

Regarding Cindy’s observation about the disappearance of the private physicians: UCSF Medical Center used to be a place in which private docs practiced shoulder to shoulder with full-time academic faculty like me. Ten years later, few of the privates remain. Many have found that handing their hospitalized patients off to our hospitalists is a better choice than managing them themselves (plus, our inpatient teams are about 1000 times better about keeping outpatient doctors in the loop than we used to be). The private physicians who want to manage their own hospitalized patients have all chosen to do so at nearby community hospitals, which are more culturally in sync with this traditional practice and, frankly, far more welcoming of them. Personally, I like having a closed medical staff – I think there is more cohesion and less variation (and less conflict) than in AMCs that mix full-time faculty and private, community-based physicians.

It is nice to hear Cindy’s observation that the relationship between our specialty services and ward teams is better. I believe this owes much to our hospitalists, who are more knowledgeable about inpatient medicine than our old ward attendings, and far more engaged. The fact that our housestaff are better rested – their inherent compassion not wiped out by sleep deprivation – may also play a role.

Cindy next addressed issues of end of life care and the tension between “doing everything” and healthcare’s apocalyptic cost curve:

The presence of a palliative care service, changes in the culture of medicine, and my comfort with palliative care that comes from living with Steve [her husband, Steve Pantilat, who runs our palliative care service] made it far easier than I remember to help cancer patients and their oncologists make the U-turn from curative/life prolonging to palliative focused care (we helped 5 patients make this transition during my two-week stretch). At the same time, I was much more aware of what felt like potentially “wasted dollars” in Medicare patients. These were patients, usually older than 80, often with some dementia and/or other chronic illnesses who came in with some sort of decompensation – often we did not really know what caused the decompensation – but we fiddled with them (treating soft-call pneumonias or urinary infections), gave the family a rest, and sent them back out, without any impact on their underlying illness.

One patient – a woman in her late 80s with dementia, bowel ischemia, serious cardiac disease, recurrent cancer, and ventilator dependence for weeks – ate up huge resources in the ICU with only a small chance of getting back home. We had lengthy discussions with the family on an almost daily basis, and they felt strongly about continuing with aggressive care despite our concern about her poor prognosis and the burdens/benefits of care. I found myself wondering whether every American (including me and my family) is entitled to this kind of very expensive/marginally effective care for free, when so many patients do not have access to basic preventive healthcare and clearly effective medical treatment.

As I’ve written before, I too believe that our modern approach to palliative care represents one of our most important transformations in the past decade. There is no question that we make this “U-turn” far more often than we used to, largely because we now have a skilled team to help us.

The tragic scene in the elderly demented woman’s room is something we see all the time. Cindy’s fresh eyes are helpful; those of us who have been doing this for years begin to get inured to it, taking some pleasure in seeing trivial numbers improve (“her creatinine is down a bit today!”) as a way of distracting ourselves from a big picture that is increasingly untenable. I wonder whether this scene is really more common than it was a decade ago or, given our increasing appreciation of the impact of healthcare costs on the uninsured, our municipal budgets, and our corporate competitiveness, simply more jarring and self-evidently absurd.

One other thing has changed: our politics. For those of us who would like to spark a mature national conversation about trying to find a way forward, the specter of being branded a death panel advocate can’t help but give pause.

Additionally, the more involved role of the attending was striking. My resident, who was superb, asked for and seemed to appreciate my involvement in holding family meetings and moving care along, especially on post-call days. She wanted me to round with the team in the ICU daily at 8:30 am. I realized I had no idea how to function as an attending on work rounds (this was something I pretty much never did in the “old days”), so I had to develop these skills. All in all, I was fine with this change, as it was gratifying to be so involved in patient care and such an integral part of the team.

Here, Cindy shares several other important insights. Our housestaff used to be passionate about preserving their autonomy. When we launched our academic hospitalist model 16 years ago, the possibility that the attendings would get more involved in care was the major source of housestaff angst. The angst has receded; our residents today seem quite comfortable, even welcoming, of having a more hands-on attending.

Why the change? In the pre-hospitalist era, many ward attendings were coming out of their research lab for a few weeks a year, partly to teach, partly to get CME from our great residents. They neither had the skills, nor the time and interest, to get down and dirty in patient management decisions. Having attendings today who are more comfortable with the issues of inpatient medicine and more readily available has helped. And, now that housestaff must complete their work in 80 hours lest they turn into duty-hour-violating pumpkins, they are looking for any assistance they can get. If combining work rounds with attending rounds shaves a few minutes, great. If the attending can meet with the social worker, or handle that 45 minute family meeting, terrific. I don’t want to imply that the housestaff are unconflicted about this – they recognize that the gradual erosion of their autonomy comes at a cost. But my sense is that most see greater attending involvement, particularly when the attendings are superb teachers and team players, as a net positive development.

I too believe that our present oversight/autonomy balance is closer to the mark than it was a decade ago – mostly because there is less “learning from my mistakes” than there used to be. But I do worry about a slippery slope, with residents gradually losing their ability to run a ward team independently, or make tough clinical decisions without first checking to see what the boss thinks. To me, this is one of the most important issues in medical education. We simply must get this balance right.

Finally, at age 47, I found the human experience much more poignant. I left wanting to appreciate Steve and my kids and our current gift of life and health, and to make sure we’re doing all we can to stay healthy.

Just think how I feel at 53! There’s no question that we identify much more with our patients as we get older (after all, we’re immortal when we’re 30, right?), and our vulnerability – the fact that we’re sidestepping raindrops all the time – is all the more obvious. After an intense stint caring for scores of very sick patients, many of whom are careening toward tragic ends, this acknowledgement can make you crazy, or grateful.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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Barry Carol
Barry Carol

If most other AMC’s are moving in a similar direction in the way they work and provide care, there is a lot to like and find encouraging here. Except for this: “One patient – a woman in her late 80s with dementia, bowel ischemia, serious cardiac disease, recurrent cancer, and ventilator dependence for weeks – ate up huge resources in the ICU with only a small chance of getting back home. We had lengthy discussions with the family on an almost daily basis, and they felt strongly about continuing with aggressive care despite our concern about her poor prognosis and… Read more »