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She said it better.

There comes a time in every writer’s life when she realizes someone else said it better.  A fellow blogger, John Mandrola, pointed out a piece in the New England Journal of Medicine that I am happy to say is better than anything I could have written.  Called “Invisible Risks, Emotional Choices – Mammography and Medical Decision Making”, written by Dr. Lisa Rosenbaum, it can be found at http://www.nejm.org/doi/full/10.1056/NEJMms1409003.  Dr. Rosenbaum talks about the ways in which patients make decisions, and how at odds those decisions can be with the scientific evidence.  Here is what what she says:

“We do not think risk; we feel it. As research on risk perception has shown, we are often guided by intuition and affect. For example, when our general impressions of a technology are positive, we tend to assume that its benefits are high and its risks are low. We estimate our personal risks of disease not on the basis of algorithms and risk calculators, but rather according to how similar we are, in ways we can observe, to people we know who have the disease. And when we fear something, we are far more sensitive to the mere possibility of its occurrence than its actual probability.”

Decision-making pitfalls are extremely common sources of poor choices.  We have to be able to predict how we will feel at a later date, for one thing.  As Dan Ariely says in his book Predictably Irrational, “To make informed decisions we need to somehow experience and understand the emotional state we will be in at the other side of the experience.”  We also have to understand the availability heuristic.  Here’s Barry Schwatrz in The Paradox of Choice, talking about a study in which people looked at newspapers and then were asked to estimate the risk of death for various scenarios.:  “People mistook the pervasiveness of newspaper stories about homicides, accidents, or fires – vivid, salient, and easily available to memory – as a sign of the frequency of the events these stories profiled.  This distortion causes us to miscalculate dramatically the various risks we face in life.”  We must also be aware of the influence of our emotions, our assumptions, who we talked to last week, prior experience, and a host of other very personal factors.

In the case of medical decision-making, fear is a powerful motivator.  Fear can turn all of us into irrational beings especially if, as Schwartz points out, it causes us to miscalculate the actual risk of something we fear coming to pass.  The current Ebola outbreak is a perfect example of this.  Every new Ebola case is covered extensively in the news, governors get on TV reassuring large populations, thousands of people can’t get into the US without someone sticking a thermometer in their mouths, and two- to three-week quarantines are instituted for everyone who knows every victim.  The fact that the incidence of Ebola in the US is currently on the order of 4/330,000,000 and that in order to get the disease you have to have had physical and intimate contact with the bodily fluids of an infected person has no bearing at all on people’s fear.

It is important for doctors to understand these pitfalls to good choice, because it affects many areas of our practice, including vaccinations, mammography, cancer screenings of all kinds, cardiovascular risk management, and even flu shots.  Read Dr. Rosenbaum’s article.  She says it better than me.

I love my anesthesiologist!

Alright, now that I’ve officially offended all the anesthesiologists I know, let me try now to convince my readers that I’m actually a big advocate of physician anesthesiologists.  They just need to be used in the right way.

The American Society of Anesthesiologists (ASA), the governing body for the specialty, has recently responded to the growing popularity of having people other than anesthesiologists give anesthesia by proposing what they are calling the Perioperative Surgical Home.  This is a terrible name for something that might turn out to be a good idea.  Here is what the position statement says:

“The ASA is currently developing the Perioperative Surgical Home (PSH) model of care.  The PSH model is a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience, from decision for the need for surgery to discharge from a medical facility and beyond.”

There are a couple of ways in which anesthesiology is currently practiced in the hospital setting that are detrimental to the status that physician anesthesiologists fear they are losing.  The first is that patients are assigned to anesthesiologists the night before.  This practice is unique among physicians.  Usually patients go to a specific doctor, develop a relationship with that doctor, and both parties develop some ownership of the perioperative course.  Most patients don’t come to a specific anesthesiologist, have no relationship with the one they are assigned, and do not consider the anesthesiologist “their doctor”.  It is like a nurse being assigned to a group of patients for the day or a waitress being assigned certain tables.  You own it for the day but tomorrow you’ll have a different assignment, maybe in a different building or a different town, doing cases that are completely different.  This makes anesthesiologists look like employees.

Secondly, there is the matter of breaks.  My husband is one of the anesthesiologists at my hospital that “runs the floor”, meaning he coordinates all the rooms and anesthesiology providers to make sure things get done in a timely manner and that room is left for emergencies.  The worst part of his job is getting all the people working alone breaks and lunches.  Anesthesiologists, when they are working alone in a room, that is, they aren’t supervising two or more rooms with residents or CRNA’s, expect to be given a 15 minute morning break and a lunch break.  These breaks might be a nice thing to have, but they reinforce, in a very powerful way to everyone in the room, that anesthesia providers are interchangeable. They can all do the same thing.  It doesn’t matter.  The surgeon certainly doesn’t consider himself interchangeable, and doesn’t expect to be broken by another surgeon.  The internist in the office doesn’t expect that in the middle of a patient visit another doctor might pop in and continue the interview to give the other doctor a break.  Getting breaks makes us look like employees.

And if we are all just employees and can all do the same thing wouldn’t hospitals choose to hire the ones they can pay the least?

What if anesthesia was run in a different way?  After a surgeon and patient decide that surgery is required, what if the surgeon said:   “you’re going to need an anesthesiologist for your surgery.  Here are the ones that practice in the hospital in which your surgery will take place.  All are good but I have worked a lot with X and Y and would definitely recommend them.”  The patient then selects an anesthesiologist, just as they selected the surgeon, and makes an appointment with that doctor.  Patient and anesthesiologist meet, perhaps in a pre-op clinic, discuss the options for anesthesia, get to know each other, and agree on a plan.  Then the booking office schedules patient, surgeon, and anesthesiologist at a mutually agreed-upon time.  When the patient then comes for surgery the conversation between the anesthesiologist and the patient, instead of introductions, goes something like “Hey! There’s my anesthesiologist!  How you doin’ doc?”  “Great, good to see you again.  How’s the dog?  Any questions about the things we discussed at our last meeting?”  The doctor can assess the patient while talking to him, noting changes from the last time, different breathing patterns, changes in anxiety level or level of consciousness.  The patient has had time to process what the doctor has said and can now ask any questions he may have or discuss changing the plan.

During the operation the anesthesiologist may have more than one patient, in fact he usually does, for revenue and educational reasons.  Here’s where the CRNA comes in.  The CRNA “does the case” in the sense that he is present and monitoring the patient throughout the case.  But the anesthesiologist is frequently in and out of each room and always present during critical times.  He has agreed with the CRNA on how to take care of the patient and they do it together.

After surgery, instead of dropping the patient off in the PACU and relying on the nurses, the PACU resident, and the surgical staff to manage his post-operative pain medication, fluid management, etc.  the anesthesiologist continues to be in charge of the patient’s care.  That anesthesiologists time is scheduled in such a way that he can see the patients he has anesthetized that same evening and again the next morning, looking for complications or assessing whether his pain management strategy is working for this patient that he now knows fairly well.  During the whole period the doctor has not relinquished ownership of any part of the patient’s course.  The patient is his patient.  The patient knows that the anesthesiologist is his doctor. If the patient needs help once he has gone home, he knows he can call his anesthesiologist. If he needs surgery again, he can call up his anesthesiologist, whom he now knows and trusts.

If anesthesia worked this way we wouldn’t need rhetoric and regulation to defend our profession.  It wouldn’t need defending.

 

 

 

A Cure For Irrelevance

Anesthesiology used to be a job that was attractive for people who don’t like patients very much.  The drill was: meet patient 5 minutes before surgery, do case in OR without interruption, drop off in PACU, done.  Minimal need for personal interaction with patient, no need to listen to complaints about back pain and demands for antibiotics for a cold, no risk of getting called in the middle of the night with a fever.  Early anesthesiologists were on the cutting edge of medical innovation, nobody else could do what they did, and patients were just glad anesthesia existed.  Anesthesiologists like to think they still are on the cutting edge, but the old drill is no longer enough.  Health care providers who are not anesthesiologists now do the meet-patient-do-the-case-drop-off all the time.  Nurses do sedation and CRNA’s do all kinds of cases up to and including heart surgery.  This scares the folks at the American Society of Anesthesiologists (ASA) and results in the turf wars I have talked about on this site before.  It also results in questions from med students, who wonder (again) about the stability of the field.

Looks like anesthesiologists are going to have to become real doctors.

Of course I don’t mean by this that anesthesiologists aren’t doctors, in the sense that we all went to med school, did residency, and take care of people during surgery.  But we have paid a lot of attention to the technical aspects of patient care and been glad to hand the patient part of patient care to others.  Being a doctor means caring for a patient body and mind, throughout health and illness.  Anesthesiologists want to “do the case”.  We have to come closer to “caring for the patient.”  The best of us already do.  The rest of us must.

Here’s a typical example of an outpatient surgical case.  Patient has a problem of some kind.  Surgeon meets patient, examines him, decides he needs surgery, discusses the pros and cons with him and his family, schedules the procedure and any pre-operative tests the surgeon thinks the patient might need.   Patient is healthy and so the surgeon waives the need to go to the pre-op clinic, where nurses and anesthesiologists see patients in preparation for surgery.  Patient arrives on day of surgery and is greeted by a nurse, who does all the initial work of making the patient feel comfortable and screening for potential problems.  At this point the nurse is now caring for the patient, no doctor in sight.  Now comes the anesthesiologist.  He reviews the information the surgeon and nurse have compiled in the patient’s chart. “Hi, How are you?  I’m your anesthesiologist.  Anything to eat or drink today?  Any problems with anesthesia in the past?  No? Great!  I’m going to put your IV in and then we’ll get going.”  So far this doctor has said Hi, read some paperwork, and done a minor procedure that nurses can do just as well.  The anesthesiologist then gives the patient a sedative and wheels him to the OR, where the anesthesia is done.  Here is where the ASA gets nervous, because it is in the OR that “midlevels” are gaining favor as a cheaper alternative.  Then the anesthesiologist wheels the patient over to recovery, gives report, and that’s the end of it.  The nurse again takes over, only calling the anesthesiologist if there is a problem.  The nurse decides when patient is ready to go home.  The nurse calls whoever is in charge of anesthesia, who comes over and signs a form that says “yes, indeed, this person can go home safely.”  Next case.

Is there any part of that that demands four years of medical school and four years of residency?  Yes, knowledge of anesthesia is required, but nothing in the previous paragraph suggests that a doctor, trained with the medical knowledge to care for body and mind throughout health and illness, has to do any of it.  The problem is the old paradigm (I hate that word) no longer applies, as nurses get advanced training and anesthesia gets safer.  As Jason Whang , author of The Innovator’s Prescription: A Disruptive Solution for Health Care, says “You can’t defend a profession by putting up regulatory and payment barriers to stop the barbarians at the gates.” Anesthesiologists have to start to truly care for the patient through the whole process.  The anesthesiologist has to be The Doctor.  The Guy.  The one everyone, including the patient, looks to as directing the care of the patient body and mind, in health and illness.  The person who, when she walks by, leaves whispers of awe in her wake.  We are doctors. We need to doctor.  Then the world will know that we are still needed.

Ebola kills people.

I owe the Rev. Jesse Jackson a congratulatory card and a graduation gift.  He has apparently gone all the way through medical school since last time we spoke.  Maybe I’ll get him a nice Littmann cardiology II stethoscope.  How else to explain his sudden expertise in international infectious diseases?  The relatives of Thomas Eric Duncan, the Liberian who died of Ebola in a Dallas hospital, have, with the assistance of “Dr.” Jackson, decided that the treatment he received was substandard and that it was because he, the patient, was African.

Yeah.  Because that’s what we do.  We healthcare providers just decide to give substandard care.  Of course we do.

Dr. Jackson is, naturally, aware of what Ebola is.  It is a virus, which means antibiotics don’t work against it.  The US, and the world, have no effective treatment for Ebola.  Here is what Ebola (EVD) looks like on presentation, according to the CDC: http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html

Patients with EVD generally have abrupt onset of fever and symptoms typically 8 to 12 days after exposure (incubation period for current outbreak has a mean of approximately 9 to 11 days). Initial signs and symptoms are nonspecific and may include fever, chills, myalgias, and malaise. Due to these nonspecific symptoms, particularly early in the course, EVD can often be confused with other more common infectious diseases such as malaria, typhoid fever, meningococcemia, and other bacterial infections (e.g., pneumonia).  The most common signs and symptoms reported from West Africa during the current outbreak from symptom-onset to the time the case was detected include: fever (87%), fatigue (76%), vomiting (68%), diarrhea (66%), and loss of appetite (65%).

OK let’s stop there.  The ER in Dallas has been roundly castigated for sending Mr. Duncan home with a fever of 103.  Given the viral news coverage for Ebola, and the fact that Mr. Duncan was from Africa, the ER should have included Ebola in it’s differential.  But remember Ebola is really very rare, with an incidence in the US of 3/330,000,000 so far.  My last bout of the flu looked just like it.

Patients can progress from the initial non-specific symptoms after about 5 days to develop gastrointestinal symptoms such as severe watery diarrhea, nausea, vomiting and abdominal pain. Other symptoms such as chest pain, shortness of breath, headache or confusion, may also develop. Patients often have conjunctival injection. Hiccups have been reported. Seizures may occur, and cerebral edema has been reported. Bleeding is not universally present but can manifest later in the course as petechiae, ecchymosis/bruising, or oozing from venipuncture sites and mucosal hemorrhage. Frank hemorrhage is less common; in the current outbreak unexplained bleeding has been reported from only 18% of patients, most often blood in the stool (about 6%). Patients may develop a diffuse erythematous maculopapular rash by day 5 to 7 (usually involving the neck, trunk, and arms) that can desquamate.

Translation:  From looking like the flu, Ebola progresses to diarrhea, vomiting, abdominal pain, chest pain, trouble breathing, confusion, headache, bleeding from gums or rectum, seizures, and rash that results in skin peeling off.

Patients with fatal disease usually develop more severe clinical signs early during infection and die typically between days 6 and 16 of complications including multi-organ failure and septic shock (mean of 7.5 days from symptom-onset to death during the current outbreak in West Africa).

Dr. Jackson, as an infectious disease expert, has a healthy fear of multi-organ-system failure (MOSF in ICU lingo).  What generally happens in severe cases is that patients get so dehydrated from diarrhea, vomiting, and bleeding, that the amount of blood in their veins can no longer provide a blood pressure that sends adequate oxygenation to the vital organs, which start to shut down and die.  In West Africa the fatality rate is 71%.  Almost three-quarters of people who get Ebola and aren’t treated adequately die.  Why aren’t the African patients treated adequately?  Because the resources required to save the life of one patient with MOSF include the following:

ICU-level nursing, multiple blood transfusion of red blood cells and clotting factors, one or more intravenous medications to support blood pressure, large-bore intravenous access, preferably into the subclavian vein or internal jugular, warehouses full of protective gear for caregivers, ventilators for lung failure, dialysis for renal failure, intravenous nutrition, gallons of IV fluids, sodium, potassium, arterial blood pressure monitoring, and state-of-the-art monitors.

In the US doctors are five per square foot.  In Africa they are five per 1000 square miles. Approximately.

Did Mr. Duncan get all the treatment US medicine could throw at him?  I don’t know, but I bet he did, at significant risk to the nurses and doctors who waded through his feces, blood, and vomit to care for him.  Because it turns out that when someone is dying we forget the color of his skin, how much they can pay, or what perceived value to the world they have.  Maybe the Rev. Jesse L. Jackson and Mr. Duncan’s family should stop assigning blame and start thanking the Dallas staff members for doing their best against a nasty disease.  Mr. Duncan died because Ebola kills people.

 

Motivation

Some of the most frustrating things that doctors encounter in their work are preventable diseases caused at least in part by behavior.  I am talking about things like type II diabetes or insulin resistance because of obesity, emphysema or other lung conditions because of smoking, liver cirrhosis because of excessive drinking, etc.  While doctors are charged with treating these conditions, many of us have no idea how to get patients to change the behavior that led to the diseases.  What patients like this need is what Daniel Coyle, in his book “The Talent Code”, calls “ignition”.  Let me give you an example of how this works.

My daughter just started piano lessons.  After the initial novelty of the first few days wore off I encountered the reluctance to practice familiar to virtually any parent I know.  She will sit in my lap with a 5-minute attention span, and that’s about all we can do.  At least it was, until her teacher suggested that the end of the lesson be reserved for playing songs and singing along, younger sisters invited.   Now, I had actually been about to fire this teacher.  He’s super nice and very sincere but seemed not to know much about children or teaching them.  I stand corrected.  The last lesson ended with him at the piano, kids gathered around, laughing and singing along to the teacher’s improvisations on “Twinkle” and “I’m a little teapot”.  The next evening I came home late from work and didn’t have time to practice with my daughter. She started whining.  Because we couldn’t practice that day.  I had to promise her that we would do it first thing the next morning, and she held me to that promise.  What was different?  The teacher’s little ignition switch.  Look how he can play my favorite songs!  I would like to know how to do that!  Look how much fun everyone is having!   She’ll probably need plenty of other ignition events along the way, but for now she’s excited and motivated.

And that’s what doctors and nurses have to be able to do.  Find an ignition switch that motivates our patients.  Such a switch is different for each patient, just as a musical ignition switch is different for each budding pianist. Finding it takes time and a well-established relationship with the patient, neither of which are in copious supply in today’s medical system.  My daughter’s piano teacher had learned enough about her to know that she loved to sing and knew most of the cannon of childhood songs familiar to American kids.  He used those pieces of information as tools of encouragement and motivation.  The overweight woman who is about to need medication for her insulin resistance needs to be known and understood by the doctor, in order for the doctor to devise an appropriate ignition switch for her.  Perhaps he knows she has a young child whom she would like to see grow up.  Maybe she wants to reconnect with an old college friend who is a runner.  Maybe she saw her own mother or father succumb to diabetes-related complications.  What if she told the doctor that she loves old movies?  Could the doctor suggest she get on a treadmill while watching Fred Astair and Ginger Rogers?  Of course.  This ignition switch wouldn’t work for the next patient, perhaps, but the next patient will have another set of values that can be used to encourage progress.  In order for we doctors to do this sort of work we must know our patients and care about what goes on when they’re not sitting in our offices.  Like my kid’s piano teacher.

How do you get to Carnegie Hall?

In case you have forgotten, dear reader, I used to be a violinist.  My oldest daughter has recently started piano lessons, and this has made me think back to my own musical training as I attempt to create in her the same love of music that I have.  In the course of my reading about learning and musical education I came across Daniel Coyle’s book The Talent Code.  In it he describes how accomplished, high performing people get the way they are.  He suggests that the key variable is what he calls “Deep Practice”.  This involves long hours of repeatedly coming up against technical difficulties, recognizing them, and learning how to deal with them.  It occurs to me that this idea is a useful framework for making training decisions that will result in happy nurse practitioners and doctors.

Medical students, at the end of training, are not really equipped to take care of people.  They have knowledge but not the practical application of that knowledge.  They must do the clinical training first, in a residency program.  This clinical training is intense and long.  It is designed to expose the young doctor to as many disease processes as possible, as repetitively as possible, so that the work of formulating a differential diagnosis becomes second nature and diagnostic and treatment decisions can be made with confidence when it is most important.  This requires thousands of hours.

Here is the parallel musical example.  When a violinist practices (clinical training) over time she is exposed to every technical difficulty (disease) she could possibly encounter, repeatedly, in multiple settings.  The goal of practice is to recognize the difficulty (diagnosis) and figure out ways to overcome it (treatment), so that she can perform with confidence when it is most important.  There is no way around this process, even if you are Itzhak Perlman.  It requires thousands of hours of deep practice.  This is also true of medicine.  There is no way around the time and training required to become a doctor.

A violinist who has been doing deep practice for three or four years has a solid training in the basics.  The violinist is qualified to play confidently pieces of music within her experience base.  She is not going to go play the Tchaikovsky concerto or audition for the New York Philharmonic.  She is not qualified to do so, nor would she want to. This does not make her less intelligent or less gifted than a more advanced player.  Knowing the basics is a great foundation upon which to build a lifelong love of music.  If she did want to play for the New York Philharmonic she would have to devote more years and specialized training at the conservatory level to become adequately qualified.

The nurse practitioner, at the end of her training, has 500-600 hours of clinical experience specific to the role of the NP.  She is qualified to confidently diagnose and treat basic problems.  This does not make her less intelligent or less able than a doctor.  She is not qualified to diagnose and treat complex medical issues, nor does she want to.  She has a great foundation upon which to build relationships with patients and with medicine for lifelong professional satisfaction.  If she wants to diagnose and treat complex problems, she has to go to medical school.

Happy nurse practitioners are happy because they have solid training in the basics and like to work at that level.  Unhappy nurse practitioners wish they were playing for the New York Philharmonic.

A Bedtime Story

A bedtime story:

Once upon a time there was a doctor who specialized in looking into peoples intestines.  He made a lot of money doing this, but he wanted to make more.  He thought and thought about what he could do to make more money.  I could charge more for my procedures, he thought, but Medicare won’t pay.  I could do more procedures, he thought, but there’s not enough time in the day.  And then the doctor had an idea.  A terrible, awful, glorious idea.  He would do the anesthesia for his procedures himself!  That way he could get paid for the procedure AND the anesthesia!  The doctor was so excited about his new idea that he published a whole paper about it in 2003 in his favorite magazine (Gastrointest Endosc. 2003 Nov;58(5):725-32.)  He continued on doing both his procedures and his anesthesia for many years, and came to think of himself as quite a smart and famous doctor.  He would have lived happily ever after except that one day another famous person came to have her intestines looked at by the smart and famous doctor.  He did his procedure and his anesthesia as he always did, but something happened, and the famous person died.  Now the doctor is famous, but for a different reason.  The end.

I know, it’s kind of brothers Grimm don’t you think?  Unfortunately this is a true story, as my dear readers have no doubt figured out.  The famous person was Joan Rivers, the doctor one Dr. Lawrence Cohen.  Now, Dr. Cohen has for some years been a vocal proponent of nurse-administered anesthesia for his endoscopy procedures, generally colonoscopies and endoscopies (scope of the stomach and upper intestines).  At my institution nurses do plenty of sedation without the oversight of an anesthesiologist, in selected patients, in graduated doses of a sedative (midazolam) and a narcotic (fentanyl), with upper limits.  For colonoscopies, in particular, this usually works fine.  They never, ever use propofol.  In his 2003 paper Dr. Cohen opined that “…propofol, potentiated by small doses of midazolam and meperidine, can be safely and effectively administered under the direction of a gastroenterologist.”

What’s the problem?  Well, I’ll tell you what the problem is.  Propofol is a powerful sedative that is also used to induce general anesthesia.  General anesthesia generally involves making someone stop breathing so that the anesthesiologist can do it for them.  Some people will stop breathing with 30mg.  Some people are still snoring at 350mg.  If a person wants to use propofol for sedation, there’s a very fine line between asleep and not breathing, a line which is different for everyone.  So propofol can make you stop breathing.  Then Dr. Cohen, in his infinite wisdom, decides it’s ok to add meperidine (demerol, a narcotic) ON TOP of the propofol.  Narcotics can make you stop breathing too.  Then Dr. Lawrence decides that Midazolam is ok to add too, because, really, why not?  It’s super irritating when he’s trying to do his procedure and the patient is moving around.

Nine times out of ten Dr. Cohen would get away with this, as long as everyone is familiar with how to mask ventilate with an ambu bag, like on ER.  Theoretically a nurse could stop the sedation and “bag” someone for the 5 minutes it takes for the propofol to  wear off.  As long as the patient is maskable, which isn’t always the case and takes experience to predict ahead of time.  It’s dangerous and stupid, but he could probably squeak by.

And even THAT would have been OK for Ms. Rivers, since she was probably maskable, except for one small problem.  If the vocal cords are shut tight, you can mask ventilate until Saturday Night Live comes on and no air will get into the lungs.  Why would the cords be shut tight?  Because the endoscopist (i.e, Dr. Cohen), is mucking about in the patient’s mouth and throat, pushing large scopes into the esophagus which is, lo and behold, right behind the vocal cords.  Now usually if you get something on your cords you just cough. BUT, if you are too sedated to cough because you have three sedatives on board you don’t cough.  Your vocal cords just spasm and you suffocate.

And even THAT would not have killed Joan Rivers if she had had an anesthesiologist in the room who knew what to do in such situations.  But she didn’t.  She had Dr. Lawrence Cohen, amateur anesthesiologist to the stars.

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