Sunday, July 29, 2012
Today I walked into the hospital and was greeted by a poster proclaiming “Physician’s Awards for the Quarter”. There were five awards presented to five different doctors. The categories were: “Best Teamwork”; “Best Documentation”; “Timely Discharge”; “Highest Patient Satisfaction”; and “Best Hand Hygiene” (seriously).
What I found remarkable about these awards was the lack of anything that had to do with true quality of care. Medical school teaches that patients’ outcomes are the most important measures of a doctor’s skill. Accurate diagnosis, appropriate treatment and intervention which leads to a smooth and uncomplicated clinical course; this is the goal every physician should strive to reach. Those five categories of awards certainly contribute to the ultimate objective, but should these five items be elevated above all else? Apparently, this particular hospital values these skills above all the other qualities that are part of being a physician. Therefore, in the spirit of competition and the current Olympic Games, I’ve begun a training regimen that will lead me to garnering one, perhaps all, of these coveted quarterly honors.
Start with “Best Documentation”. I’ve been diligently working to lengthen my admission and progress notes by adding a wealth of superfluous detail that I’m sure will contribute to near perfect outcomes for my patients. Surely every patient admitted with a bowel obstruction caused by an incarcerated incisional hernia demands daily documentation of their history of pet ownership as well as the make and model of the first car they may have owned. I’m doing all I can to match the record of a hospitalist I’ve worked with, who used to do a complete 5-6 page history and physical on every one of his hospitalized patients on a daily basis. This extraordinary documentation was topped off , after sifting through all the pages of redundant information, by an illegible assessment and plan. I’m sure I can exceed even this lofty standard.
It may be a bit more difficult to garner the gold for “Best Teamwork”. Unfortunately I still ascribe to the archaic model of physician writing orders on patients, having the nursing staff then read these orders and carry them out in a timely fashion. Obviously, such a dictatorial system cannot survive in these progressive times. It is true that there have been times in the past, mostly out of frustration, when I’ve crossed out the word “Orders”, a common heading at the top of the page in the appropriate section of the chart, and written in “Suggestions”. But, such an act is most definitely unenlightened and will never help me in my quest for this coveted award. I’m just going to have to begin to manage my patients by committee, with the therapeutic plan coming from a joint decision fostered by all the interested parties including physician, nurse, respiratory therapist, physical therapist, dietician, patient aid, hospital administrator and insurance company. Teamwork at such a level cannot fail to be rewarded.
But, what about “Timely Discharge”? Surely, first place honors are out of reach for a General Surgeon. After all, it almost always takes several days following the typical colon resection until the patient is ready to eat and be sent home. There is no way a surgeon can compete with those internists who can begin treatment for pneumonia or a UTI and then ship the patient off to the nearest Long Term Acute Care hospital. I don’t see a simple solution. I suppose I could transfer all my post op patients to an LTAC under the care of an internist. It’s true that the patient may suffer, but I would only utilize the most skilled internists and the finest lower levels of care. And, we’re talking about individual glory here; patient outcomes must take a back seat.
“Highest Patient Satisfaction” should be one of the easiest awards to win. All I would have to do is not charge for my surgical services. Perhaps this would be a bit too drastic. Maybe a rebate on the services rendered, $50 for cholecystectomy, $100 for a colon resection, and so on. Even this may be too much. I think a $5 gift certificate to Burger King would suffice and would be much simpler, and more appreciated, than actually taking the time to listen to the patient, or explaining the proposed treatment plan and potential complications. Something tangible is always better than empty words.
Finally, there is the most competitive and closely judged competition “Hand Hygiene.” I’ve thought long and hard about the best way to compete. Of course, I wash my hands over and over again, every day. Obviously, something more is needed. Therefore, I propose to take personal hygiene to a new level. Instead of mere handwashing, I intend to wash myself completely from head to toe before entering a patient’s room. In the interest of total cleanliness I have proposed to the hospital administration that every patient room have a place, for those physicians that are serious about stopping the spread of some of the nasty “bugs” that inhabit our hospital, to completely disrobe, thoroughly sterilize their entire body and then don sterile garb. Such hygiene will make the hospital the envy of every health care facility in the world and all the nasty infections and resistant bacteria we battle will vanish, almost overnight. A bit pricey? Perhaps, but the desirable “Hand Hygiene” award would be mine for the taking.
Tuesday, July 24, 2012
In the not so distant future:
Dr Intensivist stared into the room where Miss P. lay on her hospital bed, the only noises were the steady rhythm of the ventilator and the beeps of the EKG. Dr. Hospitalist stood nearby.
“Miss P. doesn’t look too good,” Dr. Intensivist remarked.
“I know,” replied Dr. Hospitalist. “Her blood pressures been trending down and she’s only making miniscule amounts of urine; white counts up to 30 thousand, too”
“What did the CT Scan of her belly show?”
“Nothing much, just the colon was a little dilated, otherwise it was normal.”
“Well, something’s not right. Her bicarb is 15, lactate is 12.”
“Do you think it’s in her belly?”
“The CAT Scan didn’t show anything.”
“Good point. Maybe we should call Dr. Cut?”
“But, the CAT Scan is normal. We don’t need a surgeon”
“I guess we’ll just continue to support her, It’s a shame really, she’s only 65.”
“We’ve followed the protocol to the letter, so we’ll be safe.”
They both stared at Miss P. from the doorway and shook their heads, almost simultaneously.
“We should check the protocol again. Let’s see, Sepsis, abdominal pain, acidosis, high WBC, hypotension, unremarkable CAT Scan. There’s a space here for physical exam. Did you examine her?”
“I did when she came in; she was soft, very minimal tenderness, nothing much.”
“Let’s see, comorbidities. End Stage Renal disease, Insulin Dependent Diabetes, Aortic Stenosis. The Protocol says probable pneumonia with Congestive Heart Failure. Treatment recommendation is dialysis and antibiotics. Well, Dr. Nephron dialysed her yesterday and her blood pressure is only 80; I don’t think she’ll tolerate another dialysis.”
“Protocol says start pressors…she’s already on Levophed and Vasopressin. Protocol says prognosis is hopeless.”
“Well, if she’s not better by tomorrow, we’ll need to do something.”
An impossible scenario, couldn’t happen, one may think. Think again. A similar case played out about a week ago. The only difference was the patient was 88 with fewer comorbities. The patient was admitted to the ICU and seen by the Intensivist, Hospitatist and Nephrologist. She was clearly septic and was on Levophed and Vasopressin, but not improving, On the second hospital day and Infectious Disease Specialist was consulted. He came in the early evening, the patient now in the hospital for twenty four hours. Despite the CT Scan that revealed only a dilated colon his abdominal exam suggested she had peritonitis.
He consulted General Surgery, me, and I saw her almost immediately. As reported, the CT Scan revealed very little. She was intubated and being mechanically ventilated, but she was alert. I asked her if her belly hurt and she nodded in the affirmative. I lightly tapped on her abdomen and she winced in pain.
She was taken to surgery in short order with a preop diagnosis of ischemic or gangrenous bowel and underwent a subtotal colectomy ( and a splenectomy, incidentally, nobody’s perfect) for gangrenous colon. She is now recovering, slowly. Looking back through the chart, the only physician that noted an abnormal abdominal exam was the ID consultant. It is possible that she did not manifest the obvious signs of peritonitis earlier in her hospital course.
I do know that as more and more “protocols” are developed, which is a major goal of the Affordable Care Act (Obamacare), this scenario will be played out on a regular basis as standardization of care leads to consistent levels of mediocrity. Is that to be the future of Medicine?