Saturday, December 15, 2012
I had a conversation with a Family Practice physician today, a man who is far closer to the end of his career than the beginning. He is part of a private practice group that recently was sold to one of the larger hospital groups in the area, which put him on a salary, but also allowed him to work only three days per week. He stated that the decrease in earnings was more than compensated by the better lifestyle and benefits he receives while being an employed physician.
He also commented on how their group practice has changed. There are several physician’s assistants and nurse practitioners within their group. They handle the acute problems: sore throats, URI’s, etc. He spends his time caring for his long term chronic patients, most of which are on multiple medications with multiple co-exisiting medical conditions. “They take more time,” he said, as a statement of fact, not a complaint.
“Managing such patients requires a knowledge of disease interaction that our physician’s assistants and nurse practitioners don’t understand.” His words, not mine.
I thought about this for a while and thought even more about my general surgery practice and the way medicine is practiced in all the hospitals I attend.
Look at the typical scenario: a patient comes to the ER, sent by a Primary Care physician who doesn’t admit to the hospital. The ER triage nurse sees the patient and orders a battery of tests, lab work and imaging studies and then reports to the ER Physician, who looks at all the tests, may go to see the patient briefly and then decides on that patient’s disposition.
A very ill patient will be admitted to the ICU, with hospitalist as attending, consultation with an intensivist and any other appropriate specialists and the patient is cared for by committee. Renal monitors the kidneys, GI does the inevitable endoscopies, surgeons go by and palpate the belly and order Abdominal CT Scans, Infectious Disease changes the antibiotics and orders lines changed and, in the middle of all this is a very ill patient and family trying to get some idea of what is going on. The answers come in dribs and drabs.
“The abdomen seems OK,” I’ll tell them, “The primary problem is pneumonia.”
“I think it’s a UTI,” Pulmonary states, “there may be s a touch of pneumonia, but I don’t think it is the primary source.”
“Kidneys are improving, BUN and Creatinine are lower,” Renal reports.
All the while the family sees Grandpa on a ventilator, multiple IV’s, five different continuous infusions blinking on and off, intermittent piggybacks and numbers flashing on monitors which may or may not represent good news. The family wonders: “Does anyone really know what’s going on?”
I wonder myself sometimes. But, through all this the patients usually get better, because of or in spite of the multitude of specialists. It is different for my patients that undergo surgery or have a specific condition that falls within my scope of practice. I usually know every detail about such patients, every lab and imaging result, the latest vital signs, urine output and overall physical condition. These ICU patients are usually seen twice a day and I always call in the evening to check on them. That’s just my paranoia and belief that surgical patients need the care of someone who truly understands their particular surgical disease.
This brings me back to the topic of this article. The inexorable rise of mediocrity in health care.
I have read several articles recently about the changes that are occurring in medical education.
“There’s too much medical science to learn; no individual can know everything.”
“We need to emphasize compassion and ethics in medical education, learning the science of medicine should be de-emphasized.”
“If a patient asks me a question, I usually excuse myself from the room, then look up the current literature on ‘Up to Date’ and then give them the ‘evidence based’ answer.”
If this is the way medicine is being practiced then why do we even have four year medical schools, or residencies? Just give a few basic courses in smart phone utilization and turn the student loose to diagnose and treat based on the latest evidence based practice.
There is an assumption in the practice of medicine, commonly made by insurance companies, government officials, hospital administrators and, probably, many practicing physicians. This assumption is that one doctor is as good as another. One GI doctor is the same as any other, all general surgeons are equal, or that every interventional radiologist is the as good as the next. Of course, being flawed human beings, this can’t be true. Those of us who care for the sickest patients know it isn’t true.
How do we know? The fruits of the labor give the answer. Infection rates, lengths of surgery, recovery times, complications all are indicators of an individual’s quality of care. From the choice of patients, to the timing and type of intervention, to the post operative management, each step requires thoughtful decisions and judgment. Our government strives to eliminate such judgment, reasoning that standardization of care, protocols and appropriate monitoring will lead to improved outcomes. If only humans were automobiles.
Years ago I cared for a mounted policeman, not mounted on a horse, his mode of transportation was a bicycle. I first saw him with rectal bleeding. He was hospitalized and an extensive workup revealed internal and external hemorrhoids which did not appear to be bleeding and had no manifestation of recent bleeding. Colonoscopy revealed nothing else. His bleeding stopped and he was discharged. About two months later he came to my office with a referral requesting a hemorrhoidectomy. He had experienced two more episodes of bleeding, had another colonoscopy and the only finding was hemorrhoids. He did have enlarged, symptomatic hemorrhoids so the surgery was performed. He recovered uneventfully and two months later had bleeding again. He came to see me and I referred him to a different GI specialist. Another colonoscopy revealed an AV malformation in the right colon which was cauterized and was the end of his recurrent LGI bleeding. Presumably, this abnormality had been missed on the previous colonoscopies.
Two vascular surgeons may operate on similar patients. Why does one have infections after almost every procedure while the other’s patients heal without any negative sequelae? How can one surgeon perform complicated surgery in 2 ½ hours and send the patient home in 4-5 days, while a second surgeon requires 8 hours for the same procedure and then sees their patient linger in the hospital for weeks?
Judgment, experience, innate talent all combine to create physicians who may be a cut above their peers. What is disturbing is that today’s training programs appear to be ignoring the fact that some physicians are not cut out to be surgeons, or interventional Radiologists or Cardiologists. They pass them through and send them into the world to flounder or worse. Surgeons such as these may struggle, rationalizing that it was a difficult patient and try to cover up bad results, but in the end it is the patient who suffers.
It is obvious to me that there is inherent variability between individuals, be they doctors, baseball players, musicians or ditch diggers. Most professions reward the skilled and talented individual. Top athletes, entertainers, even lawyers are rewarded. Yet the trend in the health care world is to establish strict guidelines and protocols that stifle the thoughtful, skilled practitioner while rewarding the individual who best “fits the mold.”
The truly sad thing is that such a physician has no incentive to tackle cases that may be complicated or time consuming or “interesting.”
“I’ll stick with gallbladders and hernias. And I don’t want to take ER call, those patients may be too ill and might mess up my profile. I’ll send the complicated cases to the Med Center, the gastric cases to the ‘foregut surgeon’, the colon cases to the ‘colo-rectal surgeon’ and don’t even begin to talk to me about trauma.”
Common words among general surgeons.
Today I received a note from Sheila reporting that she was free of disease on her recent PET Scan and thanking me for taking care of her. Sheila had come to me eight months ago with painless jaundice. She underwent a Whipple procedure, which is removal of the head of the pancreas, duodenum, portion of the bile duct and sometimes a part of the stomach,for pancreatic cancer and recovered uneventfully. She had travelled two hours to see me, because she had been unable to find anyone on her insurance plan that performed Whipples. She had, literally, picked my name out of her book. Admittedly, the Whipple procedure should be done by those with some experience. Have we reached the point in surgery where surgeons are not trained to do complex cases or are taught to refer such cases to tertiary care centers? But, what if the tertiary care center refuses? Such was the case recently. A patient was admitted to one of the hospitals where I work with painless jaundice and a mass in the pancreas, presumably cancer of the pancreas. She had been told by her Primary Care doctor to travel six hours to the world famous cancer center, which is just down the road from me. She, however, did not have insurance. She was turned away and showed up in the ER at my hospital and was admitted. She underwent a Whipple procedure and is recovering uneventfully at this moment.
I have similar experiences on regular basis, sometimes for conditions as simple as inguinal hernia or cholecystitis in patients who may have some sort of complicating condition. Maybe I’m setting myself up for a lawsuit. These patients, however, are often desperate and suffering after experiencing nothing but the run around from physicians and hospitals who don’t want to be bothered.
Where are all these ramblings leading? The physicians of today have given up their unique soul. To be a doctor use to mean to live a life of dedication to the medical arts and to the care of patients. The medical school selection process was highly competitive, the curriculum was intense and rigorous and those that were not up to certain standards fell away, sometimes in medical school, often in residency. The residency programs believed it was their duty to produce doctors of the highest quality, skilled, knowledgeable, ethical, and dedicated. Is this still true?