Thursday, August 1, 2013

Regression To The Menial

I was far ahead of my time.

The cachectic middle aged man had been admitted to the hospital fifty times in the last calender year. The other residents and I joked that new graduates only truly became interns after they had Leon on their service. He suffered a range of chronic illnesses, mostly respiratory, that were overwhelming to his mentally challenged mind. He often would walk off the floor with discharge instructions only to appear in the emergency room minutes later complaining of shortness of breath.

I liked Leon. He was soft and gentle. His lack of mental capabilities only made his kindness more endearing. He was anxious about the outside world and preferred the safety of the hospital confines. And I couldn't blame him, to a homeless man on the St. Louis streets, our institution must have looked quite welcoming.

After his third hospitalization in as many days, I decided to take action. I gathered the patient's pulmonologist, primary care doc, and a bevy of clinic nurses together in a room to hash out this difficult case.

The pulmonologist retrieved his cat scan, and outlined the nodules and signs of emphysema. The primary care physician reviewed his compliance record. The clinic social worker and nurses attested to his housing issues. We worked together as a team. The group consensus was that his lungs were benign, and the best plan of care relied heavily on social intervention.

I left the room feeling like, for once, Leon had a concrete plan of action. I discharged him the next day confident that we could stem the tide of hospitalizations. From time to time, over the next few months, I patted myself on the back in recognition of the fact that Leon seemed to be nowhere in sight.

While strolling through the halls of the clinic during my third year outpatient rotation, I bumped into Leon, and almost didn't recognize him. He had gained fifty pounds. His emaciated figure filled out into more normal proportions. He smiled as he walked by and waved. Moments later, Leon's primary physician filled me in on his progress.

It turns out that Leon left the hospital the day I discharged him, and walked across the city to the emergency room of a competing hospital. He was admitted, and the attending physician called our institution. This physician listened to the details of our work ups, and was informed about our team discussion. He then decided it was all bunk, sent Leon for a biopsy of his lung nodule, and diagnosed him with tuberculosis. Leon was sent to a state facility for six months for monitored medication administration.

Leon thrived. He gained weight, his breathing improved, and he had been living out in the community for six months without a single readmission.

Now I know what you are thinking. Another case of a doctor warning about the diagnostic traps of not taking a frequent flyer seriously. But my point of contention is actually more about team based care. Ahead of my contemporaries, I used the group model, now lauded by healthcare reformers, to try to "hot spot" Leon.

The problem with team based care, however, is there is often a regression to the menial. Ideas and diagnostic possibilities on the periphery are inevitably homogenized or coerced to the center by other members of the team. Extremes are reasoned out, and often those who think out of the box are marginalized.

Specialty groups have an altogether different issue. Tumor boards and such often make extreme options more palatable. Last ditch and low probability chemo is bolstered by like minded individuals with well meaning intentions but often little clinical evidence.

It turns out that what Leon needed was not a team at all. His savior was a lone internist, weighing the clinical evidence carefully, measuring the pros and cons, and not being clouded by the faint murmurings of ineffectual group think.


Karen S. Sibert MD said...

Excellent piece, Dr. Grumet. Certainly gives the lie to Ezekiel Emanuel's nonsense about shortening medical education and advocating medicine by committee rather than by highly educated physicians. Here's a link to another piece deploring the increasing emphasis on team-based care:

Anonymous said...

This needs to be a Grand Rounds case to remind us all how well meaning and terribly wrong we can be. You always make me ponder how and why I do what I do in my practice of medicine.