As a third year medical student, I spent one afternoon each week at a health clinic at a community hospital affiliated with my medical school. This health clinic was focused on primary care for patients with HIV, and many of our patients were poor, homeless, immigrants, or uninsured. Many were also living with their diagnosis in secrecy and had to hide their medications and medical bills from family members.
One of my patients, who I will call Clara, was a 65 year old Haitian immigrant who diabetes, heart failure, and depression, along with HIV. Due to her medical conditions, she was unable to work. She had two grown children, but they did not live nearby and did not know about her medical problems, especially her HIV. Her husband, unfortunately, was very ill and lived in a nursing home. Clara somehow managed on her own, but her lack of insurance, poor medical literacy, and limited English proficiency made it difficult for her to stay healthy, and she was constantly coming to clinic for help.
At one visit, Clara seemed unusually tired and revealed that she had been feeling short of breath at home. In my mind, this raised many questions—Could this be a heart attack? Worsening heart failure? A blood clot in her lungs? Pneumonia?
On a Saturday around noon, an 85-year-old woman was brought by ambulance to the Emergency Department with severe abdominal pain. She was confused and unable to provide any medical information. Her X-rays showed marked accumulation of abnormal air in her abdomen, a dreaded sign of a perforation in the intestinal tract. Her blood pressure was quite low, requiring treatment with intravenous medications. As the general surgery intern on call, I was asked to see her.
A physical examination showed her abdomen was rigid and extremely tender, which confirmed this was a surgical emergency. Laboratory testing indicated a serious infection, likely the result of intestinal contents leaking into the abdomen, as well as mild kidney injury. Multiple efforts to reach either family or friends by telephone were unsuccessful, and a conservator or someone with durable power of attorney could not be identified to provide informed consent. The patient clearly needed surgical intervention, so two surgeons wrote notes documenting the need to bring her immediately to the operating room as this was a “life-threatening emergency situation.”
During a 6 hour procedure in the operating room, she underwent repair of a benign perforated ulcer in her stomach. She was brought to the recovery room with the breathing tube in place only because it was late in the evening, with the plan to remove the breathing tube promptly in the morning. I saw her during a post-operative check around 9pm, and all seemed to be improving. She was now requiring much lower doses of medications to maintain an adequate blood pressure, and her kidneys were recovering with a good urine output.
About an hour later, I was notified by the nurses that the patient’s children had arrived. They demanded immediate withdrawal of support. One produced paperwork indicating that she was her mother’s durable power of attorney. She stated that her mother would never have wanted to be “on life support, intubated, and in need of dialysis or blood pressure medications to artificially maintain her blood pressure”.
Not too long ago I had the unique experience of needing the services of the emergency room of a major teaching hospital in New York City. (Don’t worry, I’m fine now.) During my thirty-four hours in the ER, I had the opportunity to observe the other patients crowded around on gurneys, in wheelchairs, or in chairs with canes and walkers resting nearby. The ER was overflowing (I was told later that their capacity is 35 and there were about 100 people waiting), and most of the people were older than 60. The doctors and nurses were incredibly busy and were doing their best to provide attention and comfort to everyone. Yet medical care wasn’t all some patients needed. The older people waiting alone needed an advocate. They needed someone to help them understand what the nurses and doctors were telling them and doing to them, someone to reassure them during the long wait to be seen by a doctor and/or to be admitted onto a hospital floor. More than several people were obviously very confused and agitated. They, like me, were waiting for hours, even days until they received care or were admitted to a room. But unlike me, they did not have family there to support them (my fiancé was with me), and they were not able to, or at least did not, verbalize their discomfort and need for food, water, or the bathroom.
After two nights, I was finally admitted to a cardiac surgery floor. I didn’t need cardiac surgery; it was just the only bed available. Every person who entered my room, from aides to meal servers, physical therapists, nurses, and doctors, was surprised to see someone under 60 on their floor. Each of them asked me, “What are you doing here?” I realized that they are so used to working with older people that someone obviously younger than 60 seemed out of place.
This whole episode got me thinking about the training hospital personnel receive in geriatrics. If everyone on the cardiac care unit expected to see a patient older than 60, and if most people in the ER were over 60, then shouldn’t all personnel receive training in geriatrics and care of the elderly? Yes, but this isn’t likely. Most medical schools do not have a geriatric curriculum or rotation, which is why the John A. Hartford Foundation provides grants to schools of medicine, nursing, and social work to help in developing more leaders and curriculum in geriatric education.
One of the great joys of a life in academic medicine is the opportunity to work with lots of very smart people. But one regret is that there is something about academia that tends to homogenize – faculty learn that, when it comes to competing for the next grant or promotion, it pays to be clever but relatively conventional. Sure, innovation is the coin of the realm, but out-of-the-box, quirky thinkers generally need not apply.
With one exception. I’d like to introduce you to the mind of Don Redelmeier, Professor of Medicine at the University of Toronto, and, to me, the most creative researcher in healthcare, perhaps all of science, today.
I came to know Don when we were both Robert Wood Johnson Clinical Scholars at Stanford University in the late 1980s, and we became fast friends. His eccentricities were obvious even then. Take, for example, Don’s algorithm for analyzing his dates, using a complex formula that assigned point values for intelligence, looks, humor, and tennis playing ability (bonus points). It wasn’t very romantic, but it was hilarious (we all looked forward to Monday recaps of the weekend’s events) and generally accurate. Continue reading…
Recently, I’ve been reading less-well known health care blogs—and finding some provocative stories.
Below, Edwin Leap–who is a physician and a blogger–tells a story about trying to find a specialist for a very sick child in the middle of the night.
Let me preface Dr. Leap’s story by explaining that, in the past, specialists who had “privileges” at a hospital (to treat patients there and to use the hospital’s very expensive equipment and operating rooms) were routinely “on call” to treat emergency patients. But these days, more and more entrepreneurial doctors are refusing to fulfill what was once seen as a traditional duty—unless they are paid.
In Money-Driven Medicine, I quote the chief operating officer of a rural community hospital who recalls a conversation with a young doctor who walked into his office and informed him that he would no longer be willing to be on call for the ER. When the doctor had signed on with the hospital, he, like all of the other physicians, had agreed to be available to treat ER patients one week a month. Typically that might mean coming into the ER two or three times during that week. But now, he explained, he wanted to spend more time at home with his children. He was not willing to continue answering the calls unless the hospital would pay him $80,000 a year.Continue reading…