Are You Listening?

He was an expert in healthcare policy.  He wrote nationally lauded papers on such things as evidence based medicine.  He spent half his time in Washington advising one governmental agency or another, the other tucked away quietly at the VA.  Originally he attended at the University, but that didn't last long.

We residents avoided him at all costs.  Not only did he piss away our precious time with verbose and often tangentially related lectures, he was down right dangerous.  The head of internal medicine knew it; our chief resident knew it.  So schedules were shuffled, teams were adjusted.  Often the strongest housestaff were pulled to work on his team, and clean up the mess he made.

Years later, I now realize, that a number of poor unsuspecting veterans likely suffered by his clumsy hands.  Thankfully, someone of authority usually stepped in before irreversible damage occurred.  It was not that he didn't understand pathophysiology or differential diagnosis.  His deficit was far more worrisome,  he completely lacked in the art of medicine.  When a patient zigged, he zagged.  He flawlessly applied inappropriate and poorly timed algorithms in a rigid and ineffectual manner.

And worst of all, buoyed by all the back patting in Washington, he was utterly confident in his abilities.

Occasionally I still hear about him from time to time.  Prancing through political circles or spouting off on CNN.  His smile is wide and confident, but I will always remember his frown as a patient circled the drain, a victim of his misapplied "science".

And I shudder, shudder to think that the politicians who currently shape our healthcare policy are listening to him intently.

I Call Bullshit

I am hard on myself. I'm the first one to point the finger inward. Every patient that dies, every adverse outcome, I study my decisions in excruciating detail. I have high standards. I don't sugar-coat the abilities of myself or my colleagues.

As the owner of my own medical practice, director of a nursing home, expert witness, and associate director for a hospice and palliative care company, I have vast experience dealing with the pitfalls of our medical system. After seeing thousands of patients, in almost every setting over the last seventeen years, I strongly question what I have been recently reading on my twitter feed.

According to a new study in The Journal of Patient Safety, preventable adverse events (PAEs) account for over 440,000 deaths a year in hospitals making medical error the third leading cause of mortality in the United States.

I call bullshit!

In my experience patients die of metastatic cancer, end stage dementia, coronary artery disease, stroke, and sepsis. Of the thousands of patients I have watched die, only a handful, at most, were complicated by preventable adverse events. And most of these happened in patients with highly involved, already terminal diseases, where the pure number of physicians and treatments multiplied the complexity.

I'm not saying that medical error doesn't occur. I'm not saying that we shouldn't have a robust bevy of researchers and experts studying the issue. None of us should rest knowing that our patients lives are at risk.

But I have to think that the extrapolations that led to this data set are faulty.

It just doesn't match what most of us are seeing in the trenches.

Death Is A Period Occuring At The End Of A Sentence

You are dying.

I have reviewed the Cat Scans, spoken to the specialists, and studied the labs. There are many possible treatments that could be offered, but I fear they will not stem the course of all that is happening already. The tumor is too advanced, the metastases, too malignant.

I know there are many questions about chemotherapy, radiation, and feeding tubes. I would caution you to think of death as the inevitable endpoint. There are many things we can do between now and that endpoint. Some will increase your life expectancy, and some will cause pain and discomfort. The trick is to decide what is more important to you: quantity vs quality. Many life prolonging treatments come at a price. Chemotherapy causes nausea and fatigue. Radiation has many untoward effects. Feeding tubes get infected and accidentally pulled out.

You must feel like all hope is gone. But I want you to know that I have great hope. Let me explain. In my experience every person, young and old, healthy and diseased, wakes up each morning with a plan for the day. Although sometimes those plans are unreachable (you will not be able to make that last trip to Florida), others are quite possible. You should expect to spend each day with your pain controlled and in a safe environs. My goal is for you to experience pleasure, no matter how small. This, I can do for you.

I do not know when you are going to die. Doctors are poor at estimating such things. But I would like to help you focus on the life each day occurring around you. Death is a period at the end of a sentence, not a parenthesis or quotation mark.

Although my role in "curing" is over, I will by no means abandon you. In fact, I will be even more engaged. You need me more now than you did when I was treating your high blood pressure and colds. We will travel this road together.

And on the day when death finally comes. You will be cared for, likely pain free,

And surrounded by love.

Buyer Beware

Gertrude wasn't able tell me herself. She was ninety years old and moderately demented. It was her daughter who called. She pleasantly greeted me as I picked up the phone.

We had a good working relationship, Gertrude's daughter and I. We navigated a heart attack and stroke, multiple hospitalizations, and many discussions concerning end of life care. Gertrude was well taken care of. She was lucky enough to have a group of helpers who were under the doting, watchful eyes of her daughter.

In fact, the last pneumonia and urinary tract infection were both treated successfully at home without need for hospitalization. I guess I took it for granted that Gertrude would be a part of my new practice. I had no doubt she could afford it. So I assumed that this would be a phone call about some pressing issue or another.

But I was wrong.

Gertrude's daughter called to thank me for my service, and inform me that her mother was moving to another office. Her voice was smooth and confident with a tinge of pride as she gushed about the first visit that occurred earlier that morning. Although saddened by the realization that I would never see Gertrude's warm if not vacant smile, I tried my best to be gracious. I offered to have my staff forward the medical records, and wished them well.

A few days later, I received a letter from Gertrude's new doctor. He thanked me for the referral, and enclosed a copy of his note. My hands started to shake as I read the assessment and plan.

Gertrude, my ninety year old demented woman, was referred for a screening mammogram and a colonoscopy. To add injury to insult, he ordered full lab work including a cholesterol panel.

No matter how depressed I am at this unbelievably inappropriate care, I can't complain. It was I who changed things up on Gertrude. I have no right to be indignant. But I would like to offer a word of warning for all those out there looking for new doctors.

Buyer Beware!

You can no longer be a passive force in your own medical care. Before you race into the bosom of a new provider, do the research. After each visit, question each new prescription and lab order.

And above all else,

Verify. Verify. Verify.

Oasis

There was nothing wrong with Sarah's vocal cords. Her tumor had spread throughout the abdomen, but her voice was unaffected. Yet minutes after learning of the voraciousness of her metastases, she pursed her lips and began to communicate with head nods and hand gestures only.

I met her for the first time in the nursing home. I sat down quietly at her bedside on a Sunday morning. I was in the midst of a weekend call rotation that would last fourteen days. Then, because of a scheduling snafu, I would have a few evenings off before starting my next two week stint. Only one weekend to rest all month.

We communicated in the most rudimentary fashion. I asking open ended questions, and she nodding from time to time. Her body was growing weak. Her belly had become progressively distended, and she was no longer eating. I called her closest relative, a sister half way across the country. We talked of hospice and palliative care.

When I spoke of dying, Sarah would close her eyes. Complex coversations were reduced to the most basic. It took almost a week to establish her wish to be DNR, and a few more days to get consent for hospice. All the while juggling multiple crises at once, my sleep schedule was interrupted on a nightly basis. There were other patients drowning in a sea of disease and frailty. And I, muscles overwhelmed with lactic acid, was trying to row a lifeboat to each lonely oasis.

When Sarah began to die in earnest, I called her sister and bayed her to come. After hours of travel, she arrived at the bedside late Friday evening. Relaxing on the couch in preparation for my sparingly precious days of rest, the mobile rang at my side. It was my answering service.

Dr. Grumet, I know you're off this weekend, but the nursing home called and said that it was an absolute emergency.

Indeed it was. Sarah was dying. Her sister was petrified and wanted me to come to the bedside. My partner on call knew nothing about the case, and the hospice team hadn't arrived yet.

And this is what's so difficult about doctoring. Our patients and their families so desperately need us to be engaged and present. Yet being there is often inconvenient, exhausting, and ultimately unhealthy. We delay sleep, impose on our spouses, and deny our children.

We met briefly the next morning. My wife and kids ate breakfast at the Panera next door as I sat with the two sisters whose hands layed intertwined on the bed. Although Sarah was fading quickly, she had just enough strength to lift her head. I barely recognized the soft syllables that tumbled tentatively from her lips.

Thank You!

They were the first and last words I ever heard her say. I nodded my head graciously,

and ambled next door to join my family for breakfast.

9/11 Repost

My dream is always the same.

It’s just another day in hell. I stand on the Bone Marrow Transplant unit. There are no windows. Suddenly the building starts to shake. The ceiling cracks letting in rays of sunlight. The ground rumbles below.


Sadness, grief, and despair spew from the floor. They rise as black lava erupting from the innards of the building and drag me to the street. I am swept forward as black death encompasses the earth and moves to envelop the sun. It carries me to the east, always to the east.

*

I've never thrown a punch. Never been in a fight or carried a gun. So if you ask me what it is like to do battle…I only have a limited set of experiences to draw from.

I did, however, catch a glimpse of the desperation of war during residency when I spent a month in the Bone Marrow Transplant unit. I felt continuously under fire, attacked from all sides, desperate. I experienced death every day.

It wasn't just the elderly. It was also the young. Mothers, fathers, children, no one was spared!

*

The Bone Marrow Transplant program during residency was large. There were fifty patients on the unit and then thirty scattered amongst the oncology floors. We had ten admissions a day, and the same number of discharges. On average one patient died every shift.

The job of taking care of these patients fell on two fellows, two residents, one attending physician, and countless dedicated nurses.

There are many beautiful life affirming stories that occur on a Bone Marrow Transplant floor.

This is not one of those.

*

I remember my last day on the unit. I spent the morning avoiding ambush. There were no codes. All our patients survived the night.

I stepped into Mrs. P’s room gingerly. Mrs. P had been in the hospital for over 6 months. She had a stubborn lymphoma that persisted despite treatment. She knew that she would never return home.

She knitted every morning as she watched the news. As with so many patients, our conversation moved from cordial greetings to a discussion of world events. I went through the motions of my examination as she recounted the most recent atrocities. They were particularly horrible today.

We did this every morning. She telling me who recently died, or was killed, or robbed. And I feigning interest although, in reality, I had lost touch with life outside the unit. The world could fall apart but I was too busy: scurrying after labs, running codes, and talking to family members.

Secretly trying to protect myself from the death and destruction that surrounded me.

If you listened closely to the discussions that we had every morning the essence of what was said would sound something like this:

“Doctor, I watch TV and see that in the world things are happening, and I am still here”. And dutifully I would respond, “Yes, yes, bad things are happening in the world and yet, thankfully, you are still here!”

Mrs. P’s days were limited. And my days on the unit were almost over. I worked twelve hours a day, every day, for a month. My time at home, in-between shifts, was surreal. I would sleep, eat, have conversations. They were mostly exhausted bridges to my next stint on the unit.

I had become a robot, a zombie.

I was withdrawing.

*

It was just another day in hell.

I sat down for rounds that morning. Mrs. P was right, things were happening in the world and strangely I couldn't’t relate. The TV above us was blaring the latest news. My attending was sitting down with his daily Tab and being prepped by the other residents.

The hum of the nursing station had reached a fevered pitch. I glanced at my progress notes and realized that I forgot to add the date and time. I looked at the clock on my pager:

10:45 AM

09/11/01

The world had instantly changed.

And it would take a good deal of time and spiritual healing to realize that it wasn’t just another day...

of death and destruction on the unit

Blood On Our Hands

I have blood on my hands.

No matter how hard I scrub, the fingers retain their burnt hue.

Many cannot see what I see; They cannot feel what I feel. They look at me with my crisp white coat, picturesque family, and all the trappings of middle class success. I am a doctor. I am to be envied. How dare I suggest that the profession that has buoyed me through this tumultuous economy is flawed? I should be thankful.

And indeed, I am, on those days when I see past the red. For there is a dark secret bouncing in an out of the minds of those who took this oath. None of us escape. Not even the ones who no longer "touch" patients. The pathologist has the image seared on his brain of the slide with neglected cells. The radiologist spies a lesion in every chest to make up for the one that was missed.

Those of us with our fingers deeply enmeshed in the bowels of human suffering have more tangible remindings of our shortcomings. How many decisions were made with the best intentions but faulty logic? How many lives were taken? I'm not talking about malpractice here. That's too easy. I'm referring to climbing out on the branches of thousands of small decision trees with simple yes or no answers but dyer consequences.

How many of the rest of you live with the fallout of these type of decisions?

How many of you can track the fatherless child, the husbandless wife, or mourning sibling to a choice that you were in charge of making?

I can.

No one told me that no matter how many lives I saved, there would be scars, wounds that would never heal. No one told me that like the most base of murderers, I too would have blood on my hands.

This is my privilege. This is my envy.

I grew up without a father. I understand the pain of premature death. I am fully aware of the consequences of my decisions.

I would not choose this profession for my children.

The pure act of doctoring is enough to give merit to the sacrifice. But today we practice a bastardized art. The power of touch has been overtaken by expensive machines. A knowing glance and kind smile have been reserved for the computer screen.

And true love and empathy have been replaced by fear of a tort system that accuses and a government.

A government bent on destroying a profession we hold most sacred.

Worrier In Chief

Saul couldn't have been a nicer guy. The story behind his arrival to the nursing home was long and sorted. But now we had a black gangrenous foot to deal with. The culprit, not the toe ulcer that brought him in to the hospital in the first place, but small thrombosed blood vessels from heparin induced thrombosis and thrombocytopenia, a reaction to a medication given as a precaution.

The vascular surgeon was equivocal, amputation versus watchful waiting. Toes can autonecrose (self amputate), but when the black tide of dead tissue spread towards the ankle our options became limited. As the white count began to rise, I had the wound care nurse unwrap the limb. Fluffs of inflammatory transudate soaked the dressing but no signs of active infection.

The leukocytosis (high infection count) was bothersome. Although the course of vancomycin had been long finished, the specter of clostridium difficile remained. And of course there was the polycythemia to deal with. A bone marrow disorder, the white count could shoot up for almost any reason, especially since he had been taken of the hydrea (treatment for polycythemia) as a precaution while treating the bowel infection.

So there were multiple possibilities: inflammatory reaction to necrotic tissue, C Diff, polycythemia, other infection? When the diarrhea began it was almost a relief. Cultures were resent, vancomycin and flagyl started, and daily INR's to track the interaction between coumadin (started to allay the risk of clotting with untreated polycythemia-hydrea on hold because of C Diff) and antibiotics.

Saul, though, had no fever, no abdominal pain, and the diarrhea slowed within days of starting antibiotics. But the white count (infection) was now heading towards thirty and the platelets were over a million. I tracked down the infectious disease specialist while in the hospital and briefly discussed oral antibiotics vs intravenous Tygacil. I paged the hematologist and we debated restarting hydrea in case this was just a noninfectious leukamoid reaction.

When cases are starting to get out of control, I like to sit and talk to the patient. Saul, bless his heart, was probably too demented to understand the complexities. His daughter, however, was involved and interested. We discussed the upcoming surgery. We talked of my clinical impasse between infection and inflammation. She was more concerned with her dad's comfort than prolonging his life.

And Saul was as happy as a lark. His functional abilities were declining, but his biggest complaint was being stuck in the room due to isolation from his infection.

Ultimately I decided to give the antibiotics a little more time. I held off on hydrea, and gambled that the high white count was more a reaction to the foot necrosis and less so infection. I watched tentatively at his bedside, visiting the nursing home daily.

Saul's dilemma bubbled up in my mind, even at home. Occasionally waking in the middle of the night with a startle, I wondered if I was missing something.

With time the white and platelet count started to abate. The diarrhea disappeared. A surgical date was set and another flurry of calls was made to figure out the anticoagulation. Coumadin needed to be stopped, lovenox was risky given the HITT syndrome, and no one wanted to put him in the hospital for agatroban. The hematologist thought that Arixtra would do, and be a nice middle ground.

Saul is by no means out of the woods, but there are signs of improvement.

***

When people ask what an Internist does, I sometimes have to pause. Unlike common perception, our job is much more complex then treating colds. We are not just followers of our specialists directions. What always surprises medical students is that when the lab results come back, or the phone rings in the middle of the night, the specialists are long gone. Often I have to take all the information I have gleaned over time, and make the call.

Hydrea or no hydrea.
Infection or inflammation.
Aggressive treatment or palliative care.

I guess I would say that my job is to think deeply, build consensus, and help families plan. I do this for a few in the hospital, seventy in the nursing home, and two thousand outpatients.

Everyday.

Call me an Internist, a primary care doctor, or a flea. The sign on my office door will tell you how I feel about it.

Worrier In Chief

The Anatomy Of A Hospital Admission

If Hattie had but one flaw, it was that she held her doctors in too high esteem. It was not unusual for an eighty year old woman of her culture to want to please her cardiologist. So when her blood pressure came up a little high, she was too embarrassed to admit that she had forgotten to pick up the toprol and hadn't taken it in over a week. The cardiologist hemmed and hawed, he buried his head in the computer, and eventually wrote for norvasc, a new blood pressure medication. What he didn't do was ask about whether she had regularly taken her pills. He also forgot to tell her that leg swelling is a side effect of the medication

But Hattie wanted to be a good patient. She squinted her eyes tightly and bowed her torso respectfully.

So you want me to take both the toprol and norvasc?

The cardiologist shook his head vigorously in affirmation as he reached for the door knob. He looked back, half his body already out of the room, and asked if there was anything else. By the time Hattie tried to lift her voice to answer, he was long gone. The waiting room was full and surely he didn't have time to stay around for her.

The next week, Hattie arrived at her primary care doctor's office for a diabetes check. After arriving thirty minutes late, he reviewed her chart. Although he read the cardiologist's note, the eleven page novel was so dense that he missed the part about the new prescription. He spent the majority of the visit clicking away at his computer, and making sure Hattie was up to date with her Hgb a1c and lipid monitoring. When he was about to zoom on to his next patient, she leaped up to catch his attention.

But the swelling in my feet, what is causing the swelling in my feet?

Befuddled by his computer, rushing to get to the next patient, and thoroughly annoyed by trying to address an issue other than diabetes, he sat back down and scrathced his forehead. The blood pressure was low and the legs were indeed swollen. Under intense pressure, he quickly reasoned that this must be an exacerbation of her congestive heart failure. He looked up at the clock and then down at the patient. He didn't re review the patient's medications. He didn't get on the phone and call Hattie's cardiologist. These precautions would have taken too much time. Instead he wrote her for a prescription of lasix ( a diuretic which would lower her blood pressure further) and ordered an echocardiogram.

Two days later, Hattie showed up to the emergency room dizzy and short of breath after lifting heavy boxes in ninety degree weather. She was dehydrated and had low blood pressure. This is exactly what would be expected to happen to an elderly woman who:

1.Inappropriately was put on an extra blood pressure pill because her cardiologist was too busy to ask about whether she was compliant with her medications.
2.Inappropriately was diagnosed with congestive heart failure instead of norvasc induced lower extremity edema because her primary care physician failed to illicit the history of a new medication or call her cardiologist.
3. Was exposed to high ambient temperatures.

And what happened in the emergency room? The ER doc read the history in the electronic medical record of congestive heart failure, examined the patient and saw the lower extremity edema, and incorrectly gave Hattie IV diuretic.

It was only hours later, when the hospitalist sat down at Hattie's bedside, that the tale of her woes came clearly to light. He ordered IV hydration, stopped the lasix and norvasc, and restarted the toprol the next day when the blood pressure came back up. Then he sent her home.

Now you may read this diatribe and think that my point is to trump the benefits of hospitalists or talk about the terrible diagnostic abilities of outpatient physicians.

But what I really want to say is that good doctoring takes time and concentration.

Both are commodities that most well intentioned clinicians caught in the dictates of our flawed healthcare system,

no longer have the luxury of.