I’m at that age, 67 going in 68, where it is reasonable to yell at the clouds. Which, come to think of it, may be a good title for another collection of my SBM essays.
Aging does indeed suck, but it is, usually, better than the alternative. As we, and by we I mean my family and me, age we get the endless joys of accessing health care. I have it pretty good. Straight Medicare with a supplement. No way would I ever go on an advantage plan, given I have already spent enough time arguing with those institutions when I was in practice. I am only two years into retirement, so I still know most of the doctors who care for me and mine. Still, I am much more of a patient, as virtually every organ system save my liver, which I exercise fastidiously, is on that slow fail that proceeds oblivion.
I will admit that, as a patient, I am not always so impressed. There is a long tradition of doctors writing about becoming patients and they have an epiphany about what it means to be a patient. This ain’t going to be that kind of essay. I have had multiple medical issues over the years and I have found the experience to be fine. My care has always been professional and caring. Still the case. But of late? So some observations, taken with a gain of salt substitute, about some trends for the practice of medicine upon me and mine.
Half-Assed
Half-assed was the term my father often used to describe the result of my chores around the house as a kid. In retrospect, I can’t disagree with his assessment. I wish I had asked him before he died if a good job would be full-assed or zero-assed. I guess it depends on whether the goal is full or zero.
But I have been impressed with how often the basics of medicine are perfunctory. Cursory? Desultory? Superficial? No, I’ll stick with half-assed.
What I am referring to is so many health care providers I am in contact with as a patient or an observer (such as when my wife or mother sees a doctor) do a half-assed history and maybe a quarter-assed or three quarter-assed physical.
It is sad.
When I have a medical problem, I organize the history before I see the care provider so they get a classic presentation of the history of the present illness, like I learned as a medical student. Six minutes tops, succinct and perfectly organized. So I know my providers are getting the right information to make a diagnosis. I do recognize there is the problem in that my presentation also includes my bias as to what I think my problem is. I am well aware that, in regards to my own health, I am not the most reliable of historians or clinicians. The doctor who diagnoses himself has a fool for a patient and an idiot for a doctor and all that.
But for some family members, I have witnessed the most superficial of history taking. I know why. The abdominal pain that brought them into the ER? Going to get a CT to see what’s going on. So why bother with a careful history when the technology and blood tests will likely reveal the diagnosis? I am old and old school. I was taught and practiced that a careful history determines the diagnosis and then the tests are ordered to confirm that diagnosis, not to make it.
And when the CT is negative, everyone looks baffled because they have not bothered to make a clinical diagnosis first. Surprise.
I also find that providers rely more on what they read in the chart than what the patient has to say. And that is always a mistake. I learned early that the best approach to a new patient was to go in mostly blind and gather the information needed from the source. I was kind of an asshole, for when I was called for a consult I told them I wanted no more than a 5-word question they wanted answered. I assumed everyone else had it wrong and the approach occasionally paid off.
And the exam?
How many heart /lung exams have I seen that were both brief and through the gown or shirt? Too many to count. One anesthesiologist’s stethoscope was not on my chest for a complete cardiac cycle. It is rare to get a cardiopulmonary exam done that I think would provide any meaningful information to the examiner.
And abdominal exams? Usually a brief push on the belly while the patient is sitting up. I have yet to see anyone do the classic look, listen, percuss and palpate.
Most of the time, I just laugh, as I know the exam isn’t likely relevant. I have no cardiopulmonary issues and do not need a heart or lung exam before surgery. It is not like they are going to find an undiagnosed aortic stenosis that might cause an issue with anesthesia. But it might be with the next patient if they bothered to really listen.
So why are the exams so half-assed? I think two reasons. One is that technology is better than the exam, although more expensive. You will get more information from an ECHO or a CT or an ultrasound or an MRI. Or even a chest X-ray. My pulmonary attending years ago said the lung exam is what you do while waiting for the CXR to develop. And I kind of agree with that.
But finding pathology is fun and, on occasion, you will pick up pathology that the technology will miss. Little things, but important. How many times did I note the patient had blue sclera and talking with the patient revealed they likely had Ehlers-Danlos, unnoted for decades? Or the embolic event in the nail bed that meant endocarditis? And the exam can confirm what you think is the diagnosis from the careful and complete history. If you bothered to take one.
The main reason these exams are half-assed? Docs can bill at a higher level if they do them. So even if you have no heart or lung issues, you will get a half-assed heart-lung exam to bump up that billing code. I never did that. I was told many times that I could bill more if I did, but I never thought it was ethical to provide unneeded care for the sole purpose of billing. Everything you do for a patient should only be for the benefit of that patient.
I should add there is a difference between the initial physical and the follow-up physical. An initial evaluation by your HCP should be complete. After that? Likely should depend on what the problem is.
I will say the exam is not always half-assed with all health care providers. The docs I see often do the exam correctly. But they are all old, at least in their 50s. I have found the younger the provider, the more half-assed. And, sadly, MDs are more half-assed than NPs or PAs.
Grumpy old fart grousing about the youngsters today. And get off my grass.
Surgical Dunning-Kruger
Medicine is difficult. Very difficult. Trying to diagnose and treat patients with the most up-to-date information is hard. I always thought the online textbook UpToDate should be called ImAwaysBehind.
There are a lot of reasons why docs are slow to change practice. I often followed the motto of ‘Be neither the first to accept the new nor the last to abandon the old.’ But the medical literature exists to be applied. I admit sometimes it was uncomfortable. The first time I gave high-dose gentamicin or oral antibiotics instead of intravenous for an osteoarticular infection, it felt like I was performing an unnatural act. Nice thing about unnatural acts: they rapidly become natural.
When treating infections, you always want to provide optimal therapy. If you have several options with equal efficacy, then you go with the least toxic and least expensive. Unless you have a dysfunctional work environment. I know the following was not meant to be an indictment of the hospital work environment, but this is in the New England Journal of Medicine by way of an ID doctor at one of the premier hospitals in the US, Brigham and Women’s Hospital, Here is the meat, with inside baseball/inside infectious disease commentary. From On the Inpatient ID Consult Service, Oral Antibiotics Have a Rocky Road to Acceptance
I bring you now a blended version of several conversations I had with surgical colleagues when I recommended oral antibiotics for their patients:
Me: I heard from your resident that you wanted a PICC line (an IV used for home antibiotics MC) for Mr. Smith. Did you see our consult note?
Surgeon: Thanks for following him. No, didn’t read it — what did it say?
Me, not at all surprised that the attending surgeon didn’t read our Masterpiece:
This is a blended version, so evidently, it is common for surgeons, later identified as Dr. Orthopod P. Neurosurgeon, to not bother reading the consult note. Jesus. Dr. Orthopod P. Neurosurgeon chooses to be ignorant of the advice of experts? Right there, you have a problem. As the attending physician, surgeon or otherwise, you should know what is going on with your patients, and that includes reading the consultation you requested.
My masterpieces were always read, in part because I made them readable. A consultation was rarely more than a page and a half typed, and ended with a concise summary of what the patient had, what tests and therapy needed to be done and a few abstracts from the relevant literature.
I will note as an aside, and I do not know if it applies here, but ID docs often take a perverse pride in writing extremely long notes instead of getting to the point. As if they are paid by the word and not the deed.
We recommended that he go home on trim sulfa, one double-strength tablet twice daily. (I might have said Bactrim. OK, I did.) The organism is susceptible, and it has excellent oral absorption. That way we can spare him the PICC line and all the risks and hassles of home IV therapy.
Surgeon: This was a very severe infection — I’d prefer we be as aggressive as possible in treating it.
Me: Understood. But there’s literature now showing that oral antibiotics are comparable to and safer than IV. I’m especially comfortable in recommending it when there is a high GI-absorption option like Bactrim, a susceptible bug, and there has been source control, as in this case.
Surgeon: Thanks for sharing that — I’m not up on the ID literature, but this infection threatened to get into the joint (or bloodstream or CNS — it’s a generic conversation). In the OR, we drained frank pus, and had to copiously irrigate the site with 3 liters of sterile saline.
Me: Yes, I understand it was bad. But it sounds like you got it all — that’s probably the most important thing. Another thing, he’s taken Bactrim before, and we know he tolerates it well.
I too am annoyed by the term frank pus. How is that different from pus? It isn’t. And 3 liters? That’s not much. I use more when I wash the dinner dishes or flush a toilet. Not impressed.
Treating infections is first and foremost about the source control. If the infection is drained, then it is mostly cured. Wanting to give IV under these circumstances is a waste. In the Middle Ages, they did not take prisoners, and it was someone’s job to walk the battlefield and cut the throats of the wounded. For many infections, that is the role of antibiotics. They don’t win the battle; they dispatch the remaining losers. As I like to say, no debridement, no cure. Know debridement, know cure.
I’m not up on the ID literature. Note, the data suggesting that oral is equal to IV for a variety of infections had been building since the turn of the century. One definitive study was Oral versus Intravenous Antibiotics for Bone and Joint Infection in the NEJM in 2019. Five years ago. It is hardly cutting edge therapy. Dr. Orthopod P. Neurosurgeon has been willfully ignorant for half a decade. And allowed to bully others into providing second-rate care.
Surgeon: Maybe use orals for a milder infection, but not for an infection this severe. I told him after the surgery he’d be going home on IVs. If we use oral antibiotics and it fails, I’d feel bad we didn’t attack this as hard as possible with IV antibiotics.
Well, perhaps you should not give antibiotic advice when you do not know of what you speak. Leave it to the pros from Dover, and yes, I know they were surgeons. I have long noted there is only one sign in medicine that is 100% sensitive and specific. Anyone who thinks a given antibiotic or its route of delivery is big gun, strong or powerful is an idiot who is a Jon Snow about the treatment of infectious diseases. Bet you a dollar Dr. Orthopod P. Neurosurgeon uses those or similar adjectives. The only question is if an antibiotic gets necessary levels in the body space that’s infected. Bacteria don’t care how the antibiotics get there.
Me: OK, we’ll set up the home antibiotics.
Surgeon: Great, thanks so much. Really appreciate your help.
Oops. The Pros from Dover shanked it into the water. Sigh.
Me: No problem. He’ll go home on 6 weeks of IV colistin.
(That’s an ID joke, ha ha. It really was ceftriaxone.)
Oddly, I am not laughing and I am a (retired) ID doctor. Just isn’t funny.
The rest of the essay is a justification for what looks to be a very dysfunctional work environment preventing the patient from receiving optimal care.
So what is wrong here? The person with the least knowledge is deciding on the care of the patient. This jackass, and Dr. Orthopod P. Neurosurgeon is a jackass, a Dunning-Kruger personified, gets to decide on the best antibiotic therapy. Dr. Orthopod P. Neurosurgeon would not tell an oncologist how to treat a cancer or a nephrologist how to do dialysis. Yet somehow she gets to determine the antibiotics? Next up, RFK Jr. will take over the infection control program at Brigham and Woman’s.
As an aside, this can be a problem for the infectious disease doctor, where other physicians feel they can ignore or change ID orders. That happened to me, but very rarely. I tried to be relentlessly nice as a consultant. Always considered the five A’s of being a doctor. Ability, Accountability, Affability, Availability and Appearance. Well, 4 out of 5 ain’t bad. But if you are nice all the time, when you do get angry, it makes an impression. I would channel my inner asshole and I would ask the offender: Would you change an oncologist’s orders? Would you ignore the nephrologists dialysis orders? Are you board certified in infectious diseases? Do you have 25 years of experience taking care of patients? Do you read the ID literature? (Which the above Dr. Orthopod P. Neurosurgeon commonly and unsurprisingly, does not.) Is it not profoundly disrespectful to ignore my expertise?
After than I had no further issues. Had a reputation that way. So the rules were clear. Consult me, we do it my way, because, unlike you, I actually know what the hell I am doing. I’m responsible. Otherwise do it yourself.
There are cases where the best approach is uncertain and requires a consensus. And there can be many reasons you would opt for IV instead of oral therapy. But that is not what was being presented here. This is meant to be a clear cut case with oral therapy that is appropriate but not provided because of Dr. Orthopod P. Neurosurgeon.
The patient went home on equivalent but far more expensive and potentially toxic therapies for no other reason I can see but to appease the uninformed ego of Dr. Orthopod P. Neurosurgeon.
I have seen no end of odd complications of home IV therapy, from line infections to lines breaking off and moving downstream to the pulmonary artery to transfusion requiring blood loss when the dog chewed off the IV cap while the patient was asleep.
And no end of patients who lost jobs, houses and had to declare bankruptcy from the expense of home IV antibiotics. I think it is unethical to send someone home on unneeded expensive and toxic IV when oral therapy is equivalent for the sole reason of appeasing Dr. Orthopod P. Neurosurgeon.
It could be argued, and is, that there are many ways to skin a cat, and that the outcomes are equivalent.
Imagine if you will (we watch the Twilight Zone every New Year’s Day while we de-Christmas the house, so Rod Serling is fresh in my mind) you are driving down the street and the check oil light pops on, conveniently next to your car dealer. You pop the hood and check the oil. Dry. No oil can be catastrophic.
It turns out there is a loose connection and the mechanic finds all you need is a quick bolt tightening and 6 quarts of oil. Instead, the car salesman says you need to replace the oil pump, put in a filter you don’t need, gives you 6 quarts of the new synthetic, Rocefoil at 10x the cost, and keeps the car for 4 days to do it, so you need a rental to get to work.
Same outcome either way. And you were not told all you needed was a bolt tightening and some 10W40.
And if you were told? You would be fine with that? Doubt it.
To paint with broad brush strokes, from what I could tell from conversations with colleagues over the years, this sort of practice is more common in academic than community hospitals and more common on the East Coast than the West. But I ain’t getting my orthopedic or neurosurgical infection treated in Boston by Dr. Orthopod P. Neurosurgeon anytime soon. Way too dysfunctional a work environment to assure me I will be getting the best, safest, least expensive treatment. And I wonder just how good the cardiopulmonary exam of Dr. Orthopod P. Neurosurgeon was.
Nepotism
So, are you interested in the NBA? Specifically the Portland Trailblazers? Because who doesn’t like to suffer? I am married to a hardcore Minnesota Vikings fan. I know suffering. But if you are interested in the Blazers, allow me to be a Joe to his Hunter, or Donald to anyone but Mary, and point out that my son has a new podcast, Blazers are Cool. If you want the wit, the charm, the trenchant analysis that only a Crislip can offer, check it out. Like and subscribe. And I will let you guess which one is my son.