I have a confession. I have been interested in issues skeptical since high school when I came across a copy of the Zetetic at Powells. In the pre-digital era I had a complete library of Zetetic-Skeptical Inquirers (SI) that a decade ago was tossed in the recycle bin along with a similar collection of MacWorlds. I have been interested in skepticism a long time and, here is my confession, I no longer find much of the subject matter covered by SI all that interesting. Even big ticket topics like the existence of God are uninteresting. It is not that the topics are not important, they are, and each generation has to relearn why Bigfoot or haunted houses or UFO’s are nonsense. But for me it is a large serving of been-there, done-that.
So while I subscribe to SI, it is more from a sense of obligation to support institutions I think are important than from an expectation that I will be either educated by the content or entertained by the style of the writers. I usually skim the magazine while accomplishing tasks that do not require my full attention probably because SI is the only magazine I still receive in dead tree format, the rest of my life being digital.
So I ran across “Taking our medicine: What hope for skepticism in healthcare?” by Kenneth W. Krause and after skimming it I was irritated. So I read it again and I was more irritated, which is often a good sign. But I could not quite put a finger on what it was. So I read it again and then went for a walk and thought about it.
All the facts were fine. I had no issue with the content of the article. It was the adjectives that irritated me. And the essay was, from my perspective, incomplete. It was like reading a relationship/birth control article by the Pope. Sure, he knows the facts of the situation, but not being an active participant in the process and with an agenda to promote, vital information will be missing or distorted.
Regular readers of the blog know my background. For the last 24 years I have spent most of my waking time taking care of inpatient infectious disease patients in Portland, Oregon. My hospitals are not for profit and several are teaching hospitals. As Chair of Infection Control I have also been involved in many of the quality and safety initiatives in my hospitals. I have gone from the young whippersnapper to one of the old geezers at my hospital and am one of the few who have institutional memory as to what has happened in health care over the last quarter century.
For those of you who want some Science-Based medicine with links and references, this essay will come up short. This is a reflection about what it means to be a physician and how it may impact patient care. It is based on me and my experiences and observations. It is probably not applicable beyond the walls of my hospital and perhaps the walls of skull. Just today I was talking with a colleague who travels widely as part of her job and she was contrasting the culture of East coast and West coast medicine and noted that in Portland we have a distinct shortage of ABHD’s (arrogant butt head doctors) and that the academic docs in ****** (I do not want her to even remotely be at risk for getting in trouble) are a vicious bunch of backstabbers. So your mileage may vary.
The basic thesis of the essay is probably summed up by the following quotes:
[The] so called “medical-science” and American healthcare in particular prospers best in a self-serving culture of secrecy, arrogance and denial.
Medical overuse is a money-hungry green monster, say healthcare experts Rosemary Gibson and Janardan Singh. It not only “thrives on the fact that too little scientific evidence exists to justify a great deal of today’s medical practice,” it also “wants to prevent good science from informing policymakers and the public about what really works.”
He characterizes patients as “easy marks” evidently about to be swindled by “common and expensive overuse” of the medical industrial complex. Evidently doctors and hospitals are conspiring to give everyone unneeded expensive care.
There is no shortage of perverse rules and regulations with unintended adverse consequences in medicine. The biggest change I have seen in health care revolves around length of stay. In the old days a patient would be admitted, you would do a history and physical and generate a differential diagnosis, a list of possible processes that could cause the patients symptoms.
The patient has, say, a fever of unknown origin (FUO), a notoriously difficult diagnostic problem. In the old days the definition for FUO was a fever that persisted after 14 days of evaluation in the hospital. 14 days in the hospital. Wow. And I was always amused that Madeline was evidently admitted for a month for a simple appendix removal. But I digress.
Then you would order tests for the more likely causes, wait for the tests to come back, evaluate them, then do the next tier of tests, methodically working though the possibilities, sometimes taking several weeks to reach a diagnosis.
These days with length of stay an important driver of cost and reimbursement when a patient is admitted, all possible diagnostic tests are ordered at once, regardless of how likely the result will be. It drives me nuts to see, but in the era of short hospital stays it is better to get everything all at once and see what the final diagnosis is. It is one change that certainly drives increased testing. This is one example of many where rule changes in payment or care have had unintended adverse consequences for diagnostic testing. No good deed ever goes unpunished.
The article makes doctors and hospitals all sound like greedy dirt balls out to scam our patients and he gives numerous examples of the over use of medical care and its consequences, all driven by the need to make money. And I will reiterate: all his examples are true. But incomplete.
Everyone wants to make money, even ID doctors. Hospitals are expensive. The payroll, infrastructure and utilities are expensive. My hospitals spend millions a year in free care on the un- and underinsured. There are some doctors and institutions that are driven primarily by the need to make money, but making money does not appear to be the primary driver for testing for those I work with.
Medicine has a lot of uncertainty in diagnosis and treatment. I have been at it for 30 years and it does not get easier with time, you just get more comfortable with your limitations. I wonder how much increased medical utilization revolves around the more fundamental concepts of responsibility and accountability.
When I see a patient I am responsible for making the right diagnosis and treatment and often there is a lot of uncertainty with both. If I am wrong people can suffer and die. Even if I am correct, the decisions I make can result in harm or financial ruin. It is often our responsibility and accountability to our patients that can drive medical testing.
After my Dad retired from a career as a cardiologist I noticed he became more alert and active and I commented it must be nice to be rested after a lifetime of night time calls. He said it wasn’t the calls that ruined his sleep, although he received enough of them, but it was the worry that kept him awake. The worry that his patients would do poorly and the worry that he was doing all he could to make them better. I understand that worry. Bedtime is the time to perseverate about patients, to worry and fret about them, often to the detriment of a good night’s sleep.
Early in my career I had a patient admitted Friday afternoon with fevers for two weeks, a new aortic insufficiency murmur and conjunctival hemorrhages. Endocarditis (a heart valve infection), I thought. Get blood cultures and start antibiotics and I didn’t think I needed to call the tech in for a weekend ECHO. Aortic valve endocarditis is a dangerous disease that can decompensate quickly, but the patient had no signs or symptoms of valve failure so there was no need for the ECHO as the patient had no indication for surgery. I left for the weekend.
When I get back from the weekend the blood cultures were still negative and I was puzzled. They should be growing something by now so I ordered the ECHO and there was no endocarditis. Instead there was a dissecting ascending aortic aneurysm, a very rare mimic of endocarditis. I have not seen one like it before or since. I had sat on a dissecting aneurysm for 72 hours.
I do not know what is the worst thing that can happen in your job. In mine it is that through error, omission or commission, I injure or kill someone. You cannot imagine the sense of mortification I felt that I had missed a diagnosis that easily could have killed the patient. He was repaired and did quite well, but to this day I cringe when I think of the case. It is not for medical-legal reasons. I do not give a rat’s ass about being sued. I care about not hurting patients. I care about making them better. The more certain I am with my diagnosis, the more likely I am to not miss an unexpected diagnosis and the more likely I will give the appropriate therapy.
And that is nothing compared to the feeling when you discover that a patient who you thought was doing well has taken a turn for the worse. A couple of years ago I had a malaria patient who was admitted on Thursday and by Friday I thought he was doing well. But when I returned on Monday he was on a ventilator and ECMO, almost dying from severe malaria. I did nothing wrong mind you, it was the natural history of the disease. You can do everything right and still have a bad outcome. But that horrible sinking feeling of dread in the pit of your stomach you get when a patient does poorly is something everyone wants to avoid. It is horrible when a patient does badly because I am responsible and accountable for that patient, even if I do nothing wrong.
And that in turn is nothing compared to the feeling when a patient dies. Jesus. Even though I did everything right, a death is awful. The horrible sinking feeling of dread in the pit of your stomach is magnified many-fold. I am responsible and accountable for my patient and death and complications are a failure of that responsibility. As a recent blog entry noted
“Of course,” the young surgeon said, with complete sincerity. “Everything is my responsibility.”
That responsibility has consequences, the most important of which is
When a person trusts you with his life, the bucks stops with you.
I want to maximize the chance that my diagnosis is correct since the consequences of being wrong can be horrible. It is a difficult calculus as to how much uncertainty about the diagnosis is reasonable. How many tests do you need to maximize diagnostic certainty? A lot of tests get ordered to increase the certainty. You need the right diagnosis to embark on the correct therapy.
There is also the worry that the patient has an unlikely process that if missed could be catastrophic. If you think a patient could have a pulmonary embolism, a blood clot to the lung, you will probably order a CT even if it is low probability because if the patient did have a PE and you miss it they could die. And as a corollary you remember those surprise diagnosis of the past, the ones you didn’t expect that were revealed on CT or MRI. Sometimes testing yields unexpected and important pathology and those cases often have an excessive effect on future testing.
And unfortunately part of diagnostic utilization is due to the ghosts of failures past. If you have ever missed an unusual diagnosis on a prior patient you will remember it far more clearly than your successes. And if a similar clinical situation arises, or even one that is close, you are likely to order the tests even if the diagnosis is unlikely.
It is always a difficult road to walk: you want an accurate diagnosis, you know that everything you do can cause harm, you do not want to miss a catastrophic diagnosis and you do not want to repeat past mistakes. And this in the context of initial uncertainty as to the diagnosis.
And above all I want to help people get better. I doubt most people reading this will believe it, but what drives most of us in medicine is to make our patients better. I want to relieve their suffering, cure their infection, improve their health and get them back to their life. Unfortunately the medical literature so often is not clear cut as I would like as to what to do for patients. It is a constant problem applying the literature to a specific patient who may not match the profile of the patients in a study. You have to do your best with what you have and above all you have to do your best for your patient.
Arrogant is an interesting term used for physicians. It has certainly been used to describe me. The interwebs say it is “having or revealing an exaggerated sense of one’s own importance or abilities.”
Which is a curious adjective. I am expert in my specialty and few in the US have my knowledge base or my experience. There are about 8,000 ID docs and 660,000 physicians in the US out of a population of 314 million people. With the exception of those ID docs who have been at it longer than me, it is safe to say I know more ID than most doctors and everyone else in the US. If you are admitted to the hospital with an ID problem, there is no way you will ever be able to gather the knowledge required to make an independent decision about your diagnosis and therapy.
I find it odd how the expertise of physicians is denigrated. I do not see it with engineers (if drivers were more involved with bridge building we would have better bridges) or pilots (flights would be on time if more passengers were involved with flying the plane), although I suspect there are even more jailhouse lawyers than ersatz physicians.
An even more difficult problem in health care is health literacy, which is “the ability to read, understand and act on health care information” and depending on the demographic, affects half of Americans. We have a physician in our system with an interest in health literacy who has been a champion for improving and simplifying the material provided by the hospital. As an example, we are rewriting all out material so it is at a 6th grade reading level, the US average. As Dr. Breger likes to point out in his lectures, half of patients do not have the wherewithal to understand medical care, and
40-80% of medical information is forgotten upon leaving the provider’s office or facility and nearly half of the information retained is incorrect.
What we really need is a better class of patients and physicians, where all the patients are strong, all the doctors are good looking, and all the health care is above average. But we are stuck for the time being with humans, with all their flaws. While most would like their physician to be an unholy blend of Marcus Welby, a boy scout and God, the reality is vell, Doctors are just zis guy, you know?
It would be nice for patients to aggressively represent their own interests, but most cannot, especially when they are ill. Probably half the patients I see in follow up do not remember having seen me in the hospital because of medications, stress, sleeplessness and other factors. Perhaps my bedside manner sucks as well. For good or ill, given the complexity of medicine and the limitations of many patients, it is my responsibility as your doctor to be your advocate and to strive to make the right diagnosis, start the right therapy and get you better. The best most patients can get is a Readers Digest understanding of their disease.
The characterization of medicine as filled with money grubbing bastards who provide unneeded and dangerous care for profit is true, but narrowly true, one small aspect of health care, and of all human endeavors (except, of course, journalism), but not all of health care.
“Taking our medicine” was at its core the kind of essay I would expect from the Health Ranger or Dr. Mercola, although not reaching the levels of total nonsense of Food Babe in its understanding (my current standard for the ultimate in health illiteracy).
“Taking our medicine” has familiar construction I often find in the SCAM world. I see similar articles every day; it is the first time in my faulty memory to find a Mike Adams-style essay in the skeptical world. These essays have a pattern:
1) Present facts but make sure they are without nuance or context. Mention the deaths from health care but conveniently fail to mention the responses: The Institute for Healthcare Improvement’s 100,000 Lives Campaign, which in 2006 claimed to have prevented an estimated 124,000 deaths in a period of 18 months through patient-safety initiatives in over 3,000 hospitals. Or the 5 million lives campaign. Or any number of quality improvement initiatives that have occupied my time and improved patient care.
The amount of work we have done to decrease complications in my institutions has been prodigious. We have applied, to use Mr. Krause’s quoted phase without his intended irony from the quotes, “medical science” to patient care and in our system we estimate that we have prevented over 2,000 infections and 200 deaths since 2006. Mentioning medical complications without noting the response to those deaths is a sure sign that the author is disciple of Andrew Lang.
As is, I suppose, putting doctor in quotes, as he does in the essay. It is probably the equivalent of calling me Mr. instead of Mark or Doctor or Crislip or hey you. In the blog comments, calling one of us Mr. is probably 100% sensitive and specific that the writer is a wackaloon, especially if addressing Harriet or Jann.
2) Use inflammatory adjectives and phrases that cast your protagonist in the worst light possible: self-serving, secrecy, arrogant, denial, money-hungry, green monster, highly-caffeinated, gleefully sell anything, easy marks, misplaced trust, lucrative, cozy economic relationship, forsake journalistic integrity (no, not the author in SI, a different forsaker), dysfunctional, left in the dark, etc.
3) Make sure there is an aura of conspiracy. Doctors and hospitals are monolithic institutions that are working to prevent you, the consumer, from knowing the truth so that they can bilk you out of your hard earned money, harming you in the process.
4) Make sure the protagonists are represented as totally evil and without redemption. Never mention the good. We probably killed Kenny as well.
5) Have simple, yet all encompassing, solution. Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. ~H.L. Mencken. Twain or Mencken as Americas best writer ever. Discuss.
Or maybe not. Perhaps I am a gullible, biased and naive, an apologist for the medical-industrial complex. It is probably my ongoing confirmation bias, but the only two articles I can remember concerning real medicine in SI are this one and the Spector article and they were both suboptimal. At least when SI has an article about a SCAM they have authors who know the topics; I am not so sure it applies to real medicine.
Again, every problem with medicine noted by Mr. Krause is true and I can come up with many more. Medicine in the US is a mess in many ways and I have no good answers short of making me the all-powerful emperor of healthcare.
Medicine is also an incredible profession. At the end of the day I can look in the mirror and know that I have made someone’s life better, I have relieved suffering, cured a serious illness, prevented an early death, decreased morbidity, made the diagnosis missed by another, eased anxiety. In my job I make the world materially a little bit better every day through the practice of good, science-based medicine.
I am also of the opinion that being a doctor is more than being a “human being providing a competitive service.” It is odd as a lifelong skeptic and atheist to consider medicine a higher calling, with obligations and responsibilities for service to my patients that transcends a technical-financial relationship. But I do. It is why I have patients, never clients or customers. That is an old school attitude that I do not always live up to, but I try and it marks me as an anachronistic dinosaur. Damn it Jim, I’m a doctor with all the intangible responsibilities that accompany the job.
I find the job impossibly complicated, filled with uncertainty and I never seem to have enough knowledge. If I am lucky and careful, I get through the day without complications or bankrupting my patients. But I start every day with gleeful anticipation of the challenge, the responsibility and the fun that I know is to come and finish each day satisfied that I did my best for my patients with the tools at my disposal. Despite the many flaws there is no better job or more noble profession.