Thursday, April 9, 2009

patient views - The Doctor-Patient Has the Floor

As I lay flat on my back on the mobile hospital bed, after the cath and the stent, tethered by intravenous fluid lines, health monitoring leads, and devilish device called Femstop, a pressure–driven plastic globe pressing down on my femoral cut- down site to prevent a hematoma, a quote from a talk by Alistair Cooke, “The Patient Has the Floor,” delivered at the Mayo Clinic in 1965, came to mind.

Cooke said. in part,

“I wish to talk of the fears of some statesman, lawyer, or other grandee who never appears before a doctor except to have his chest tapped, his knees jerked, his tongue depressed, his innards photographed, his rectum protoscoped, and his juices filtered, measured and pronounced upon. It is, though you may not know it a permanently humiliating relationship: I mean the relationship between doctors and the rest of mankind. And it is because most people do not care to bring it up in public that I believe it might be useful for me to do so.”

Hospital Experiences and Impressions

Well, I thought it might be useful for me to talk about my experience and impressions as a doctor of being a doctor-patient in a modern hospital. Certain professional courtesies go with being a doctor, and I appreciate the kindnesses extended to me. I became aware that knowing precisely what was going on facilitates being a patient.

I would not describe the relationship between myself and other doctors and the hospital as “humiliating “ but rather as mix of helplessness, appreciation, and curiosity.

I looked upon my hospitalization as an opportunity to study what makes the modern hospital tick, to talk to caregivers about their hopes and anxieties, and to see how my perceptions of the system matched realities. The best way to do this is tell the tale of my heart attack.

The Pain

Eight days ago, substernal pressure discomforted me. I thought I had heartburn, so-called GERD (gastroesopheal reflux disease). That ought to have been a clue to my misdiagnosis. One rarely has GERD for the first time at my age 75. In any event, the discomfort, a dull ache, 3 or 10 on a scale of 10, didn't respond to Prisolec and Maalox – another clue, he who treats himself has a fool for a doctor.

Anyway, I have no personal or family history of health disease. But I had clues of coronary precursors – an untreated blood pressure of 140-150/85-90 and a recent gout attack. but my lipid panel – total cholesterol 141, LDL 69, HDL 47 and triglyerides 120 – was clean as a whistle and gave no indications of an impending occlusion. Though I considered a heart attack, I dismissed and denied the possibility.

The pain came and went, was worse when I lay down, better when I sat up. It didn’t radiate, and wasn’t accompanied by sweating, nausea, dizziness, shortness of breath, or pain on exertion. It persisted for three days, and the third night, it prevented sleep. On the morning of day of day 4, I felt unwell, and my wife drove me five miles to an emergency clinic five miles away, where my general practitioner had directed me to go.

The Bottom-Up Functioning of the System

The ER visit began my bottom-up view of the health system. I sometimes write about the health system being viewed from the top-down, i.e., from Washington, and not from the bottom-up, from the grassroots. To me the most useful solutions to health care usually emanate from the clinical trenches, not from federal bureaucratic back benches.

The ER physician, an athletic-looking, alert forty five male, quizzed me briefly, did an electrocardiogram, and drew blood. Ten minutes later, he informed me I had suffered an myocardial infarction, had classic ECG and enzyme changes, gave me nitroglycerin to relieve pain, and ordered an ambulance to transport me to a academic medical center 45 minutes away for a heart catheterization . Ours was a no-nonsense conversation, and with me being a doctor, no explanation was needed.

The Ambulance Ride

On the way in, I interrogated the emergency medical technician (EMT)... He was 40 years old, father of three, and a full-time firefighter who worked 16 hours a week at an EMR to make ends meet. He told me heart attack riders like me were more frequent in the spring, and he was riding side saddle in case my pain worsened or I arrested.

He gave me my first insight into the new technologies. Technology is said to account for 70% of health care inflation, and it comes in all forms, large and small. He said a new device had come onto the market. The device could be placed under and on top of the patient and delivered chest compression as rates of up to 100 beats a minute. This device, and the more pervasive presence of external defibrillations in public places, in his experience, had increased immediate survival rates after arrest to about 40% compared to 5% in the past – not a bad investment – considering the alternatives.

The Cath Lab

Upon arrival at the hospital, I was whisked directly into the cath lab – large room bristling with overhead imaging equipment, tables strewn with procedural gear, and three or four nurses and technicians bustling about getting ready for the cath.

I was informed I was one of the 12 “caths” for the day (about 4 million cardiac catheterizations, inpatient and outpatient, diagnostic and interventional, are performed each year in the U.S., and roughly 1.5 million of these result in “stents” to bypass blockages. Other developed countries do about one-fourth as many caths as the U.S. Whether we do too many, or the rest too few is upon to debate.

About 30 minutes after I arrived it was done – a right femoral artery cut-down and placement of a drug-coated stent in my circumflex artery. The typical patient, I was told. received 1.7 stents per cath. I was awake during the procedure, heard some chattering between the cardiologist and his crew during the procedure, and experienced little pain other than a lidocaine stick before the femoral artery cut-down. After the procedure, the cardiologist explained precisely what had been done and what to expect.

Off to the Intensive Care Unit and then to the General Cardiac Ward

Then it was off to the ICU where my rhythm and vital signs were constantly monitored. I was told to stay flat, not to raise my head, not to cross my legs, but to wiggle my toes. A parade of cardiologists, cardiology fellows, nurses, residents, nurse assistants, a nurse practitioner, medical technicians, and others followed.

Each was unfailingly courteous and scrupulous about reading my wrist identification band. Each asked I had pain (pain estimates are now regarded as a vital sign), most listened to my chest, and felt my ankle pulses (important when you’ve had a femoral cut down). I had a Phillips heart wireless monitoring device in my gown pocket, which displayed my heart rhythms at the nursing desk.

Who is Interviewing Whom

Many people came to interview me and check me over, but it often ended by me interviewing and checking them over. I made a point of asking each and everyone their name, where they were from, who they came to be health professionals, and how they viewed the system.

When it became evident my vital signs had stabilized, I was sent to the general cardiology ward, where I had the luxury of ordering my own food from a menu. The assortment of choices was impressive, but because I was on a heart diet, no salt or sugar was allowed, and the food tasted flat.

The State of Mind of Health Care Personnel

Most nurses were pleased and preoccupied with their work and didn’t complain about the terms of their employment. A few groused about the ceaseless paperwork and endless requirements to record and duplicate the same data in multiple locations. One nurse unfurled a three foot long spread sheet with multiple columns like a paper accordion. Some of the older nurses expressed skepticism about chances for health reform under the Obama administration and foresaw a flurry of more regulations.
They may have a point. I’ve read that 25% of hospital costs are devoted to meeting federal regulations. The volume of paperwork to meet regulations is certain to increase with programs to meet all quality indictors and to show irrefutable evidence that safety standards have been met.

Among doctors, doubt and apprehension about present and future workings of the system were more prevalent. The younger doctors in training openly worried about paying off $200,000 educational debts, and many candidly said they would not enter private practice as general internists and instead would choose work as hospitalists, proceduralists, emergency room doctors, with regular hours and predictable income. A friend of mine, Dr. Paul Grundy, Director of Health Care Transformation at IBM. divides the doctor world into “comprehensivenists” and “partialists.” It’s my impression in the academic setting, the “partialists” are winning. Specialists, by the way, don't appreciate being dubbed as partialists, which they take to mean they aren't real doctors.

EMRs and Data Systems

Two of the younger doctors had received part of their training at the VA. Although they found the VA’s EMR system functional and useful, they doubted if it would work in small practices. But the VA and other big health systems like Kaiser, Mayo, and the Cleveland Clinic have shown EMRs work in big systems. New York-Presbyterian Hospital centers and clinics, which provide about 20% of the health care in New York City, have just announced it will offer consumer-controlled health records for patients.

Specialist Frustrations with Paperwork

One of the cardiologists, a nationally prominent figure, commented to me, “They’re always talking about primary care doctors being unhappy. Hell, I’m unhappy too. Most paperwork in the name of quality wastes my time. The paperwork kills satisfaction and hampers productivity.” He went on, “Documenting isn’t the same as doctoring. We’re sometimes asked to be on standby if a president is in town on a weekend. The next time that happens, I‘ll tell them, ‘No, I’m a government employee, and I don’t work weekends.” He ended by say, “I would never recommend medicine as a career for my kids.”

A Grateful Doctor-Patient

On the whole, I am grateful for the care I received and for the clear explanations of what to expect. From a personal point of view, the money invested in new heart-sparing and life-saving technologies in the cardiac sphere was worth it, at least to me, and quality of care and safety of the hospital were superb.

The dangers of hospitalization in the U.S. may be overstated. The rate of adverse events in U.S. hospitals in only half that of England, Australia, and New England. I received a daily dose of subcutaneous heparin, which I was told, was to prevent pulmonary embolism, the number one cause of sudden death in hospitals. A nurse informed me subcutaneous heparin was part of hospitals efforts to follow The Institute of Healthcare Improvement campaign to save 100,000 lives in hospitals and also to avoid Medicare nonpayment for complications of pulmonary embolism.

Home Again

Six days after my infarct diagnosis, I’m now at home on the five medications routinely given to stent patients (a statin, beta blocker, aspirin, plavix, and blood pressure lowerer and rhythm suppressor) and have been assigned to a cardiac rehab unit. Sometimes in our efforts to identify villains in the health system, we point fingers at the pharmaceutical industry for profiteering and marketing activities, while forgetting the industry brings live-saving technologies to the table, which in the case of heart disease, have tremendous. Preventive as well as therapeutic elements.

At this point, I'm happy with the system, but am fully cognizant that as a physician I enjoy certain courtesies, privileges, and advantages , due in part to my knowledge of disease and the system.

Conclusion – Facing Global and Local Realities – Real-time

Nothing brings you closer to reality than being a physician. As a 75 year old physician who is just recovering from a heart attack, who has just spent five days as a heart patient in an academic heart center, and who is a frequent commentator on health care reform, I’m acutely aware of real-time realities.

When it comes to realities, I believe in thinking globally, acting locally, or, in health care lexicon, I appreciate top-down policies, but relish bottom-up innovations. America is an overwhelmingly bottom-up society, but it must act in concert with top-down federal policies.

Perhaps no one realize this more than President Obama, who has this to say in statement at a White House forum on March 6, 2009,

“This time is different because the call for reform is coming from the bottom up, from all across the spectrum — from doctors, nurses and patients, unions and businesses, hospitals, health care providers and community groups, as well as state and local officials.”

At the same time, it's Obama vision that health reform will help us cover the uninsured while cutting costs to government and corporations, and while ameliorating our long-run fiscal crisis and making businesses more globally competitive.

As much as I applaud his vision, I’m not sure it’s possible to expand coverage while reducing costs for following reasons, which were reinforced by my recent 5-day hospital stay.

• We are a technological nation that looks as the body as a machine – when plumbing clogs up, we unplug it or bypass it; when the joints cease working, we replace them; when the face of the machine sags, we lift it up.

• We are an impatient, even a spoiled nation, brimming with 78 million baby boomers becoming Medicare eligible in 2011, with a population that believes we deserve quick access to modern technology’s wonders.

• We believe in choice, freedom, and pursuit of longevity, and maybe sometimes in eternal youth, or at least the appearance of it.

• We believe in equal opportunity, but not necessarily in equal results, making it difficult to create homogeneous federal health policies that cover everyone equally in our multicultural, heterogeneous vast continental nation in which one of five Americans is a recent immigrant or a close relative of one...

• We believe in experts, in specialists in command of various organ systems and specific disease, even though this belief engenders inefficiencies, high costs, and a fragmented delivery system.

• As much as we nostalgically applaud family physicians, our Medicare, Medicaid, and the Reimbursement Update Committees (RUC) do not reward primary care doctors sufficiently to attract medical students to primary care specialties and to create a comprehensive, coordinated health system.

• The government regulatory and payment pressures on hospitals – meeting each and every quality indicator, avoiding a host of common complications for which Medicare will not pay, meeting system-wide safety standards - are enormous and create an environment in which documenting becomes more important than doctoring.

America still believes in private health care, which pays 68% of the nation’s health bill versus 32% paid by government (Medicare, Medicaid, Veterans Affairs, Department of Defense health services). I thought of this in my hospital bed, when my two successive roommates were a 28 year old and 46 year males being evaluated for heart disease. While Medicare is the biggest single payer and the Sheriff of the System who sets the pace for payment and regulatory policies, Medicare does not yet control what doctors order or what tests they perform.

Federal regulators may yet do what foreign health regulators do now:

• Reduce payments to doctors. other skilled health care providers, and hospitals.As American-trained doctors became scarce, more foreign trained doctors and physician-extenders will be needed.

• Limit medical technology. In Canada, patients have to wait for months for MRIs, so those who can come to America for immediate diagnostic services. With a nearby MRI, the tragedy of Natasha Richardson may not have occurred.

• Ration available treatment to fit the federal budget and comparative effectiveness requirements. The universal digitized health data may well be used to justify non-treatment on a cost-benefit basis.

We are not there yet.

I shall end by simply saying from my vantage point, admittedly a biased one, we have a superb medical system.

1 comment:

Anonymous said...

The economic stimulus plan adoped by Congress includes funding for the important EMR software for doctor's offices and can result in better patient care and treatment, and reduced healthcare costs.