I had a patient this week that really screwed up his medical care when he experienced a predicted side effect of curative chemotherapy. Despite clear instructions and access to every number my partners, my staff and I have, including office, triage, cell, and answering service, he did not reach out. Day-by-day he lay in bed, as he grew weaker and multiple systems failed. No one contacted me. Finally, he sent an email to a doctor 3000 miles away, in California. That doc forwarded the email to me. I sent the patient to the hospital.
Did we rush to the emergency room, to salvage his life? Of course. Were there innumerable tests, complex treatments, multiple consults and an ICU admission? You bet. Did I patiently explain to him what was happening? Yes. Did I look him in the eye and tell him that I was upset, that he had neglected his own care by not reaching out and in doing so he violated the basic tenants of a relationship which said that he was the patient and I was the doctor? Did I remind him what I expect from him and what he can expect from me? You better believe it, I was really pissed!
The practice of medicine for most doctors is fueled by a passion to help our fellowman. This is not a vague, misty, group hug sort of passion. This is a tear-down-the-walls and go-to-war passion. We do not do this for money, fame, power or babes; we do this because we care. Without an overwhelming desire to treat, cure and alleviate suffering, it would not be possible to walk into an oncology practice each morning. Therefore, just as we expect a lot of ourselves, we darn well expect a lot out of our patients.
This, apparently, is a map of my mind. It’s a little shocking to find out that my mind looks like a sea creature, a bug, or perhaps a vegetable. Actually, “Rob’s mind” and “vegetable” are often used in the same sentence.
Someone suggested to me that I may benefit from mind mapping. I don’t know how to describe it, but I think spatially; I see things abstractly as if I am pulling up from the ground and getting an aerial view of things. I write that way, I solve problems that way, I even play music that way. Maybe it’s tapping on the right side of the brain that is about nuances or about how things relate to other things in proximity or direction. Like I said: it’s hard to describe.
Anyhow, I was thinking about task-management with my patients, wondering what’s the best way to think about it and what is the best design for a system helping with this. Task management is perhaps the most important thing in health care that’s never talked about. Maybe that’s because it makes doctors feel less special, reducing our “magical” knowledge and “miracle” cures to algorithms and checklists. Personally, I take great comfort in systems because they assure me I am not going to forget important things (like setting a reminder to take the trash out on Sunday and Wednesday nights).
Policymakers, researchers, physician-leaders, and patients have all cited the need for care to be tailored to patients’ unique needs and preferences. And there is solid evidence that patient-centered care can help improve care quality and reduce costs. However, in the rush to become more patient-centered, the health care system has misplaced its focus.
Current approaches to patient-centered care are based on aggregated preferences rather than individualized needs. Researchers and health systems deploy focus groups and surveys to assess general patient preferences in an effort to determine “what patients want.” But patients are a diverse group with diverse needs. Characterizing general beliefs and preferences alienates those whose needs and preferences do not align with the majority. The result has been a monolithic view of patients and their needs — a framework that prevents the delivery of truly patient-centered care.
All service industries share the challenge of providing tailored, individualized service. In response, leaders in customer service have developed tools and infrastructure to understand and respond to individual needs and preferences. Health care providers should leverage these approaches.
WASHINGTON — While the news swells this week with sad and angry retrospectives on the war in Iraq, it is worth noting that the tremendous human costs of that war would have been much greater, were it not for breakthroughs in combat medicine deployed for the first time on a broad scale in Iraq.
4,486 American men and women were killed in the Iraq war. This represents approximately 14 percent of the 32,221 wounded in action — versus the 19 percent killed in Vietnam, or 27 percent killed in World War II. These statistics are cold comfort for those whose lives were derailed and families tormented in the process, and they are a clarion call to re-double all our efforts to help those who survived.
“The more you learn, the more you realize you don’t know.”
You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.
The implication of this for the practice of medicine is that a little knowledge can be very dangerous.
What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.
I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)
The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it, it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.
Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing. Continue reading…
I’ll admit that the question on the face of it struck me as a bit absurd, especially when juxtaposed with the term “tomorrow’s doctor.”
Tomorrow’s doctor needs to be doing a much better job of dealing with today’s medical challenges, because they will all be still here tomorrow. (Duh!) And the day after tomorrow.
(As for the 21st century in general, given the speed at which things are changing around us, seems hard to predict what we’ll be doing by 2050. I think it’s likely that we’ll still end up needing to take care of elderly people with physical and cognitive limitations but I sincerely hope medication management won’t still be a big problem. That I do expect technology to solve.)
After looking at the related Huffington Post piece, however, I realized that this trio really seems to be thinking about how medical education should be changed and improved. In which case, I kind of think they should change their organization’s name to “Next Decade’s Doctor,” but I can see how that perhaps might not sound catchy enough.
I can’t tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren’t sure of the difference between the two, then “God’s Hotel” is the book for you. It’s an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco’s Laguna Honda Hospital, the last almshouse in the United States.
Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Sweet discovered, was to the benefit of the patients.
Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, “slow medicine,” as Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.
I have been thinking about the difference between slow medicine and UCLA medicine. It has made me realize how complex and difficult it is to transform American health care so that we lower per-capita cost and increase the quality of our lives. And yet we must achieve these two goals.
Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother: Embracing “Slow Medicine,” The Compassionate Approach to Caring for Your Aging Loved Ones. Slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care.
McCullough describes slow medicine as “care that is more measured and reflective, and that actually stands back from rushed, in-hospital interventions and slows down to balance thoughtfully the separate, multiple and complex issues of late life.” Shared decision-making, community and family involvement, and sophisticated knowledge of the American health care system are some of the slow medicine practices that sharply contrast with UCLA medicine.
UCLA medicine is the status quo where the hospital is the center of the medical universe; where care is often uncoordinated and hurried, and where cure is the only acceptable outcome for both patient and physician. I call it UCLA medicine because the CEO of that well-regarded medical center was quoted in a New York Times Sunday Magazine article as saying, “If you come into this hospital, we’re not going to let you die.” This is a statement that puzzles me as an old time anatomic pathologist.