Monday, December 7, 2015

What I Believe The Public Should Know About Clinicians

The daughter of the patient walked out of the room livid.  She was convinced that the nurse had no business taking care of patients.  She seethed as she recounted all the supposed injuries and mistakes that had occurred.  I took a deep breath and paused for a moment, trying to collect my thoughts.

The daughter didn't know that I had watched this same nurse successfully perform CPR on a man the day before, and her quick thinking was one of the factors that save his life.  She had once recognized a rare side effect of a medication, and solved a clinical mystery that had hounded doctors, hospitals, and pharmacists for months.

In my mind, she was the best that clinical medicine had to offer.  Knowledgeable, kind, intuitive.

But this trend has been escalating over the last few years.  Patients and families wagging their fingers and nodding their heads angrily in the direction of clinicians.  Doctors, nurses, and therapists have been accused of being incompetent, lazy, or downright cruel.

There is a basic loss of faith in the ability of our healthcare practitioners.

I think that the Internet plays a role.  The ability to Google one's symptoms and come up with a host of diagnoses has made the populace feel that medicine is easy.  Furthermore, the lay press and some of our own physicians and administrators decry the system as befouled by errors.  They say that we account for as much death and disability as heart disease and cancer.

While I believe that medicine requires a continuous and stringent effort to improve itself, I also think that the populace is becoming progressively fooled and brain washed.

Here is what I think the public should know:

1)People die, for the most part, because they are sick.  Yes medical errors occur (even to healthy people).  But medical errors happen more often in deathly ill, hospitalized patients, with poor prognoses to start with.  The more ill the patient, the more complicated the care.  More medicines.  More tests.  More risky procedures.  More errors.  This doesn't mean that we must not strive to do better.  But all those articles about how "hospitals kill more patients than..." are ungenuine.
2)Complications are not errors.  A small percentage of people who get colonoscopies will have the unfortunate complication of perforation.  They may even die from it.  This is expected.  Same for post surgical deep venous thrombosis.  Same for deadly side effects of medications.  There is a cost/benefit ration.  We can do our best to mitigate risk, but we can't avoid poor outcomes altogether.  It's like a reverse lottery.  The grand majority do just fine, but occasionally there is a big loser.
3)A text book presentation of a disease is very rare in clinical medicine.  It happens infrequently.
4)Physicians are some of the most highly trained individuals in society.  Our education is arduous and can span more than a decade.
5)Medicine is one of the most researched fields known to man.  Billions are spent every year improving our clinical knowledge.  Our ability to treat cancer, heart disease, and injury is far better than it was even a decade ago.  Patient safety is, and has been, at the forefront of researchers minds for years.  We are making great improvements. Think anesthesia, hospital acquired infections, and surgical check lists.
6)physicians have active and time consuming requirements for continuing medical education and board certification. Greater, I believe, than almost any profession.
7)The legal system holds physicians to a high standard and the penalties can be life altering for the involved clinician.  The grand majority of physicians are sued at least once during their career.

In summary, medical practitioners are highly trained and skilled individuals who are plugged into an incredibly regulated and researched domain of human existence.

To treat them as if they are stupid or ignorant is unkind, to say the least.


Anonymous said...

Have you talked to patients out on the street? Obviously not. We are worlds apart from the reality of what you believe.

1) Medical errors happen to a lot of us still hanging around. There are thousands of us on FB alone.

2) We understand that. We are talking about obvious gaffes, like not knowing about bloodwork tests or saying something is ok when it is a slew of points above the high limit. Saying something can't be true and its in the medical research - in your own specialties' magazines at that!

4) The ability to reason is not taught though. Giving a person 10K facts but no interrelationships because everyone sub specializes and not enough GP's = disaster.

6) That doesn't mean they're getting it right.

7) The legal system is a joke. I can send you to multiple groups who will tell you that. Most of us don't sue because of intimidation, threats, harassment, gaslighting and blacklisting. I'm one of those who's had all three. I won't go into the admin & joke that is state medical boards & agencies.

Bottom line: I've seen great people, like the person you say, get it wrong. Its the ego, attitude, and evil that has been perveyed to me and others that is even worse.

Anonymous said...

I am replying to you although I know your mind is made up.

Your reply suffers from / demonstrates the same problem that Dr Grumet outlines. Perceived expertise based on internet based knowledge

1) How do YOU know they are true errors? Was it analysed clinically or based on layman perception based off of the internet rather than real life understanding?

2) "saying something is ok when it is a slew of points above the high limit" That is based on you applying a textbook understanding of limits NOT a real life understanding. Limits are statistical. Something out of bounds, may still be normal IN THAT CONTEXT, which google is not capable of recognising.

"Saying something can't be true and its in the medical research - in your own specialties' magazines at that! " again see textbook interpretation vs real life confounding factors.

3) You skipped 3 and it is the most relevant point here. Please read it and read it again. If you are not convinced, ask to shadow a physician for a month

4) That is a result of market pressures. Many many patients still seek specialist opinion to confirm and hear again the exact same thing the GP has already told them. Again " There is a basic loss of faith in the ability of our healthcare practitioners. " Maybe because of all the confusing and contradictory information from the internet.

5) You skipped this too

6) Again how are you to know? This might sound paternalistic, but really HOW do you know? Medicine is constantly evolving, different solutions work for different patients.

7) again this is based on what you perceive to be an error? which based on all of the above may not even be an error!

I would like to expand on what Dr Grumet refers to as the Internet. There are tons of wellness sites etc that peddle misinformation, even resorting to doctor bashing for ad views. The worst are the Hypothyroidism websites. Then there are the candidal overgrowth. syndrome, antivaxxers etc. And patients have no way of knowing what is legit , what is not. And patients routinely walk in convinced of their mastery of the subject based on a few website and there is no way to change their mind / educate them to what they might actually be doing wrong.

Anonymous said...

The naturopaths, I think, are adding to the mess. I see them ordering anti CMV tests etc for work up of fatigue and malaise. Patients try to get this done through the PCPs as insurance will cover it only when ordered by MDs or something. I cannot in full conscience order a test that has little utility. Bingo "Doctor knows nothing" . The naturopath / nutritionist / various other alternative medicine practitioners ( #notallofthembutenoughofthem ) is seen as kinder and empathetic, all the while not realizing they are being sold snake oil.

Diane said...

You are disconnected from reality. I usually can find some way to connect to your posts and I truly believe you are a good Dr, BUT fact is, Drs, nurses and hospitals neglect patients at shocking levels and it is occurring more frequently, or patients are finally feeling confident enough to realize they should speak out and that they should not have to suffer medical abuse or neglect in silence any longer. The lack of hand washing, the medication mistakes, the constant bedsores, and the promised gift of an infection worse then the original health issue on visiting a hospital are competing with a third world country in many hospitals across America. To be honest that doesn't even phase us,we get that you are human and make mistakes, that there are too many patients and too few well trained nurses... The denial is a symptom of the growing "blame and judge the patient " styling being exposed. If you question a Dr. you are labeled a "non compliant" patient- and either the Dr. dumps you in a hurry(instead of discussing and educating and working in partnership) or in the case of pediatrics they call CPS. We never declared war on the Drs we once trusted, it was they who in their arrogance and inability to change with the times who have declared war on the patients. We do not surrender our bodies and minds to the medical world. While I respect your vast knowledge and that is why I pay your sometimes(often) outrageous fees(some attorneys rates are much cheaper now)I am paying for an opinion. I am not signing a waiver to trust without question, to believe without research, to suffer without complaint what you deem medically appropriate. I can see 3, 4 or 5 specialists for the same health issue and get wildly varying opinions on diagnosis and treatment. It isn't the internet "tainting" patient thinking- it is the medical profession. I know NO ONE at this point in my life who has not suffered abuse or neglect at the hands of a nurse or Dr. Many have dealt with multiple Drs and nurses(because of chronic health issues) who are not only cruel, but wrong, neglectful and at times emotionally abusive. You do realize that there are patients now having to seek the care of therapists for Medical Post Traumatic Stress Disorder? Sad, right? That in order to get medical care for their broken bodies, patients are having to seek therapy to handle the way they were "given care. ". You need to step outside your bubble and listen and quit judging. It isn't hysteria, it is abuse. While it doesn't happen to all or even half or quarter but it happens too often. I guess at one point in our history it was considered okay to beat your wife, and if someone objected they would be treated like they were nuts. Drs. claiming that patients are "exaggerating" or buying into "internet hysteria"are no different then those back in the day denying spouse abuse. I have been to a couple appointments where the mental abuse would have been enough to light up toll free abuse hotlines if it had been my spouse who treated me that way. Don't get me wrong, there are great Drs and caring Drs. and great nurses and I am the first to sing their praises- but there are too many bad and unhealthy medical professionals out there too. Denying a problem doesn't exist doesn't make it go away. Maybe in this case the nurse was right and giving good care, but what about the last 20 experiences the patient or family have suffered through? Odds are they were given reason at some point to be a little paranoid.

norxgirl said...

Medical PTSD....yup!!! What i find so incredibly repulsive is the defensiveness and the obsessive combativeness with subjective intellect from most providers.....where is the Empathy? If they dont have it...well, they just dont. They mostly seem to want to engage in a battle of wits, and my education and experience trumps yours any day. F-off!! Tell that to only full term baby in the grave, after multiple miscarriages. And all the OBs I went to never had enough about themselves to go back and pull the records of patients with pregnancy losses when the MTHFR gene mutation started getting more attention. And, yes, i have it. And, yes, do does my niece who also lost a 6 month pregnancy and now has a child with Down Syndrome. She had good doctors...i did not....what a gross lack of conscience and self-monitoring. And all the medical charading around in utero DES exposure from the 40s to the 70s....OMG. When, oh when, is the medical profession going to admit culpability? Oh, and I guess all those folks getting their lives back from suicidal depression, aches and pains, walking from wheelchairs after MS misdiagnoses since using frequent B12 injections along with folate, good ferritin levels is an internet placebo. Puleeze....MD does not equate to Minor Diety!!!!! The internet has just made the esoterica of medicine less so. Compassion, empathy....primary characteristics of good practitioner...if they dont have...dont need to go into medicine....medicine should never, ever, ever have been about the ego of a clinician, is a holy calling in service to others...never about dominance and control....

Anonymous said...

Hey, Norxgirl , that's interesting, can you show me the studies of B12 curing MS? thanks

Unknown said...

I don't know you but generally in my experience medical people are pretty good at handling fear, but not all the time, and often not when it's needed the most. Fear, as you likely already know, makes some people cower or babble, and makes some people attack.

I was a consultant in computers and wide area networking for a few decades, and I also trained newbie consultants in The Ways of the Forest. The level of complication is nowhere near medicine, but this was back in the day, when computers and networks were very new and very scary, and a major project disaster could have career limiting effects on a customer. Also, as we all know, it is very important to set expectations very early on -- most arguments start from mismatches in expectations.

In my job I had to learn how to handle fear, and I had to learn how to teach my clients to handle fear. Scared people are jumpy and stupid, and stupid jumpy people can't make networks work, even if they stay late.

Mostly when I get scary news from a doctor he/she will tell me, explain what's going on, and give the details, but they will often look vaguely like they're giving an answer in an oral exam.

I'm not being snippy, these people are accurate and concise and they lay out the odds well. These are the people who since grade school have always been really good at passing tests, and to them, this is a test question. Then they (usually) just look at me expectantly for a beat, as if there is the unspoken question of "OK, are you going to handle this, or are you going to go birdshit?"

So, is that the right way to give that news? Here's what I think. What I used to tell newbie consultants back in the day was four things:

Show them the warts.
Show them the cliff.
Let them feel it.
Look them in the eye, tell them you will be there for them.

Show them the warts means that you establish, somehow, that you may be the best guy in these here parts for this kind of job, but that doesn't mean you never ever once came back from the men's room with your fly open. Nobody's perfect, but you can go flat out when it's needed, and you are a person that people trust.

Show them the cliff means that you have to tell them the worst (reasonable) thing that could happen. In detail. Usually a doctor follows this with the odds. You can tell them the odds if you want, but after that you have to look them in the eye and say something like "this could happen to you. Really."

Now comes the part that I haven't seen a doctor do yet. They have to feel it. You have to wait, I mean WAIT until you see their face change. They have to see it, see the death, see the loss, whatever. The have to get through it, and accept it. If they don't accept it at this stage, if it happens later they will want to blame somebody, probably you. So they need to accept the possibility of the bad thing before you move to the next step.

NOW you can look them in the eye and tell them that you will be with them as much as you can without being irresponsible to your other patients, and so on. Now you can set reasonable expectations.

As you can see it boils down to empathy. In your mind, as you look at them, you have to say to yourself, "I see you're scared. I would be too. I have been scared myself, a time or two, I know how it feels." If you say it out loud they won't believe it, but if you think it, it shows up in your eyes and they'll see it.

If you do this, and you look them in the eye and they seem to get it, they seem to calm a little, then you're going to have a good day. Probably.

Anyway, that's what has worked for me.

Unknown said...

I am 60 yrs old now, and as a person with many medical problems, I have been to many medical appointments. The one thing that everyone should remember is: We All Have Bad Days! It took me many judgemental years to recognize that for the most part, excluding the ultra-lazy, most people really are doing the best they that moment. I have met far too many people at church who don't seem to be aware that priests and nuns are flawed human beings, just like the rest of us. They make mistakes! I have met a 3-4 Medical Professionals who acted like they thought that they were God. None of the rest acted anything like that and just wanted to be cut some slack when they couldn't answer a question. I much prefer a doctor who will tell me "I don't know" rather than making up an answer. All medical providers have so much more information to learn than the last generation, that it's only fair to have a few gadgets to help sort through a list of common ailments to figure out a diagnosis. My husband is an older Pharmacist, and the one difference he's noticed through the years is that far too many medical care providers cannot count, so the number of pills on a script doesn't match the directions. Let's all give the people we interact with more room to breathe, because we are doing the best we can!

Unknown said...

Most of the replies on here are not recognizing the FACT that doctors and nurses' care has changed based on patient satisfaction scores and funding in hospitals at least. We are running on little hamster wheels trying to be everything to everyone. And we can't do what we are trained to do. We are stressed to the max. The only thing that can daily be criticized though would be the lack of education on the clinicians' part to patients and families. To tell folks what's going on. We need to return to some of the good old days' care when we had less patients and more time to get to know them. Hospital care has become like the fast food industry. Get em in and get em out. Dont blame the staff. Those responsible are the ceos, the govt and ins companies. Start writing letters if you want better care!