September 10, 2007 | Leave a Comment
Hey Dr. Bear, you are something of a critic of the “old school.” What was wrong with the way doctors were trained in the past and why should we change things if the old ways have worked so well?
When I was a structural engineer, I had an old-school boss who had never quite made the philosophical jump into the computer era. Oh sure, he accepted that computers were essential to the business of engineering but he obviously longed for the Good Old Days when engineers made all their calcuations with a pencil and a slide rule. He often made us check our calculations by hand and barely tolerated the use of a calculator for this purpose. His contention was that engineers were better trained and more capable in the old days and that hand calculations gave one a better feel for the meaning of numbers. The Chrysler Building, he often pointed out, was built in a time when computers were unheard of and all the engineers had were their trusty slide rules and their tables of logarithms.
There is no doubt that the engineering profession is built upon the broad foundations laid by engineers of the past. Nor is there any doubt that a healthy respect for their accomplishments and a knowledge of the basic principles that they formulated is necessary for the education of an engineer. But the engineering profession has moved forward and while respect is necessary, mawkishly worshiping the old ways is impractical and counterproductive. Not only do we know more but new methods of design and analysis have made many of the old methods obsolete. Not to mention that certain economic realities dictate that we can no longer spend a day setting up the math to solve an engineering problem when we can have the result in five minutes using any number of structural analysis and design software packages.
That’s just the way things are. My boss used to insist that if we ever lost electrical power or found ourselves on a deserted island all of us new guys were screwed. The obvious flaw in that threat is that we’re not exactly going to be doing sophisticated engineering while waiting for rescue and if the apocalypse should come, we will be too busy scrounging canned goods and fighting flesh eating mutants to even think about breaking out the slide rule.
Now consider the practice of medicine, another profession which is supported on the broad shoulders of the past. Medicine underwent a revolution starting in the late nineteen-sixties going from a sedate, contemplative profession built on slowly acquired experience to the fast-paced goat-rodeo-cum-chinese-fire-drill it is today; a profession where there is barely time to examine a patient before he is fed into the patient processing plant which most hopitals have become. It is a fine thing to long for the Good Old Days when doctors spun their own urine (whatever that is) and did their own peripheral smears but those days are gone and, to paraphrase The Boss, they ain’t coming back. Likewise, our antiquated system of residency training, as it is was designed for the slow-paced hospitals of the past, is a poor fit for the way medicine is practiced today. In the old days, when patients were usually long-term boarders for whom nothing could really be done, a certain amount of leisure time was built into the system. This leisure time was filled with rounds, grand rounds, conferences, more rounds, spinning urine, making slides, lovingly writing extensive notes, and hour-long physical exams. Now that medicine has become something of a grind, while you could take thirty minutes for a detailed neurological exam to isolate a lesion to the left posterior globus palidus, you can instead send the patient for a CT and save yourself the carfare.
Which is what happens. You can no more practice medicine today like an old country doctor than you can design a skyscraper with a pencil and a slide rule.
What is the biggest problem facing American Medicine?
Let me tell you a story. The other day I had a patient who came to the Emergency Department in the early hours of the morning with a chief complaint of constipation for twelve hours and the subjective sensation of a “turd stuck up there.” “Surely there must be more to this complaint,” I thought to myself and launched into a careful history and physical exam to ellicit something, anything, that might kill the patient or cause him serious morbidity. Nothing. Zero. No abdominal pain. Passing gas. No vomitting or nausea. Appetite good. Abdomen non-tender. No fever. No nothing. There wasn’t even any stool in the vault when I finally did a digital rectal exam in the forlorn hope of finding blood, a mass, or just about anything to rekindle my faith in the basic intelligence of our patients.
Finally, more than a little annoyed I asked the patient what, exactly, he expected me to do for him.
“I need help taking a crap,” he said as he settled back into his bed.
I gave him a lecture on fiber, told him how to access his local Wal Mart, and sent him on his way.
In a perfect world, this patient wouldn’t have even got through the door. He would have been stopped cold by the triage nurse, rejected at the net, so to speak. I have no doubt that if this same patient had presented to an Emergency Department in France, he would have been subjected to the full brunt of Gallic derision. In the United States, the complete lack of common sense, a trait that has been beaten out of the medical profession by the depredations of the legal profession, ensures that this patient and many like him tie up Emergency Department beds and suck up finite medical resources, principal among these being the time of the physician and the nurse.
It’s not that one patient really has that much of an effect. We have the beds, after all, and the worst that happens is that others who are not acutely ill have to wait. But the over-utilization of the Emergency Department by patients who are not actually sick or have no discernable medical problems for which we can provide treatment forces us to maintain an expensive infrastructure many times the size of what would be required if we limited our attentions to patients with legitimate medical problems.
The consequences of ignoring common sense extend into all areas of medicine. Everything is not a medical problem, even things that are medical problems if you can get your mind around this concept. Knee pain, for example, that is the result of weighing 500 pounds cannot possibly be treated by a Family Physicians, an Orthopaedic Surgeon, an Internist, or an Emergency Medicine Physician. When you weigh a quarter of a ton you are just going to have knee pain. It is, however, the fear of being sued on one hand and the desire for a steady stream of paying customers on the other, that keeps the clinics and emergency departments full. Job security, no doubt, but I’d rather work in a rational system based on common sense than have that kind of artificial job security.
What do I think is the percentage of my patients who have no business getting through triage? It’s hard to say. We see our share of serious medical problems and the acutely ill. But thirty percent would not be an outrageous estimate. If you had a bad payer mix, that is, a high portion of uninsured patients, it would probably be cost-effective to have a physician, and not just any physician but the most experienced one in the department, running triage to quickly winnow the wheat from the chaff, the drug-seeking back pain from the aortic dissection, and the menstrual cramps from the ectopic pregnancy.
So it is the profound lack of common sense that is the biggest problem facing American Medicine. The effects of this lack of common sense, trying to practice zero-defect medicine among a terrifically unhealthy, mostly non-compliant, and litigation-happy patient population are legion and spread their costs and inefficiencies throughout the system. What is most paper-work, after all, other than an attempt to fend off predatory lawyers and their mostly ridiculous lawsuits? There’s a doctor shortage, apparently, but I notice that I spend more time on the patient’s paperwork than I do on the patient and as most of this contributes nothing to his care, imagine how many more patients could be seen or how much more time I could spend with a single patient if we somehow could kill all of the lawyers.
Not to mention the cost of unnecessary tests and treatments undertaken because the wages of intelligent inaction are ruinous while juries, as they are composed largely of people who can take two weeks off pretty much whenever they want, smile favorably on the physician who does something, anything, even if is pointless.
What’s the most ridiculous thing about your job?
Patient satisfaction surveys. Totally meaningless and generally not worth the price of printing them, especially in Emergency Medicine where the patient may rate his visit on the availibility of parking, the alacrity with which the nurse brought him a pillow, and anything other than the quality of his medical care. We saved his life but had to cut off his expensive jeans and it just left a bad taste in his mouth.
Consider a recent patient of mine who presented with diabetic ketoacidosis secondary to not taking her insulin as the price of it seriously ate into her crack cocaine money. We did the usual things, caring for her no differently than if she were our sister and after an hour or so of being grateful, she started to feel better and the complaints and abuse began. I have no doubt that upon her discharge, this polybabydadic mother of six, all in foster care, with no means and no intention of paying a dime for her medical care was presented a patient satisfaction survey courtesy of that modern devil, Press Ganey, and asked to rate her hospital experience. Now, why we should care about the opinion of a non-paying customer who is otherwise habitually to be found turning tricks in parked cars or passed-out drunk in an alley somewhere in the seedy side of town escapes me. What is she going to write that could possibly be of use?
“I’d like to see a better variety of free samiches.”
“More dilaudid, please.”
And yet I have no doubt that each of her complaints would be taken seriously by the shadow bureaucracy that exists to bedevil doctors and nurses. The ridiculous thing is the insistence that medicine is a customer-service business like any other when it is most certainly not. It is nothing like a business. First of all, the customer is not, repeat not, always right. We do not tailor our treatment to fit the patient’s expectations, rather they come to us with a medical problem and we tell them, whether it bothers them or not, what must be done to correct it.
There is also no such thing as a customer in the traditional sense. Most of my patients don’t pay a dime for their visit and don’t expect to either. Asking for their opinion is like asking a shoplifer what he thinks about the decor or the new security arrangements. Even those with that gigantic ponzi scheme otherwise known as health insurance have no idea how much things cost, don’t care anyways, and feel entitled to as much of the health care pie as they can stomach. If there was really a health care crisis, a crisis that is threatening to swamp the system, you’d think we would be trying to discourage customers, not encourage them.
You know, like how MacDonalds has uncomfortable seating to discourage loitering.
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