Clueless

Someone named Ronen Avraham, a professor at the University of Texas School of Law, wrote an Op Ed piece in the NY Times (3/28/11) about the Obama administration's plan to invoke clinical guidelines as a solution to frivolous malpractice litigation. The good professor apparently had spoken with enough people to know that the problem with clinical guidelines is they are often written by the wrong people, and sometimes by people who have ulterior motives, e.g. to promote profit for the people the authors of those guidelines are working for. The other problem with the guidelines is they are too often written by people with the time to write them, faculty members at medical schools, who, perhaps surprisingly, are not the sharpest blades in the drawer.




I recently regaled a conference at my own hospital by simply reading from the clinical guidelines for the in patient management of diabetics which said, among other brilliant things, if the patient you are treating is terminal, i.e., if he is expected to die within a short time, then controlling his blood sugar, lowering it to normal ranges by the use of intravenous insulin may not be required, or at least it may not be as important as this practice would be for people who are expected to survive their hospitalization. Which is to say, if you are dying of widely met static lung cancer, if you have it growing in your brain, getting your blood sugar into normal range may not be your highest priority.



Ya think?



So who should be writing guidelines? And, more basic, is it really possible or wise to attempt to write guidelines at all? Is medical practice not in a constant state of flux, adjustment and re examination and is it not so complex that writing a single manual is impossible? Is this not what we go to medical school, residency training, specialty conferences to learn? It's like that old saw where the author is asked by the radio show host, "So what's your novel about, in a sentence?" and he replies, "If I could tell you that, I wouldn't have had to write the novel."





Some things are complex enough to defy simple dictums.





Then there is the case of "Medical Economics." The Obama people have their hearts in the right place: They want to provide health care for all, and they want to do all this at the lowest possible cost. But, understandably, they don't know where the hemorrhaging is. If you don't know the anatomy or the physiology, you are not going to find the bleeding point.





Not that the Republicans have any idea. What they have is fantasy. And fantasy is, at least, coherent--it makes a good story: Just let the market drive down costs. Get the malpractice lawyers out of the picture, driving up costs as they do. Stop all the regulation. Private enterprise will save all. Republicans love living in denial. They will cleave to these fantasies with ferocity, because they want to believe all this.





The Obama people, Peter Orszag in particular, have their own fantasies. They wanted to believe economists could tell them where the savings can come from. And they wanted to believe Atul Gawande had done a bone fide piece of medical economic analysis in Texas, showing the way as he described one Texas town where the billings to Medicare were very high versus another where they were close to the median as if these two towns held some sort of key. In the expensive town, it was all about greedy doctors, bilking the system by doing unnecessary tests.

So that's the answer! Search out those bogus, unnecessary tests!





Nice fantasy.





The real problems, of course, are much more pervasive and more difficult to fix because so many people are making so much money and they vote and they spend that money to hire elected officials.





A colonoscopy makes a local hospital $3400 and that's not even including the doctor's fee. This is a test which could be done by a technician for, reasonably, taking into account the overhead for equipment, cleaning equipment and staffing support, say $250 a pop and you could screen a lot more patients at far less cost. But colonoscopies are the cash cow of the gastroenterologist: he learns the procedure in a few months, masters it in a year and then supports his family and his boat payments doing this procedure which can be scheduled and is never an emergency, and he can be on his boat by 4 PM. You think the GI docs are going to give up that without a fight?





Similarly, you could replace 95% of dermatologists with technicians who could do excisions and biopsies at a small fraction of the cost people with MD's charge. This is another group which works 9 to 5 and profits are so enormous dermatology residency training programs are now the most competitive residencies out of medical school. Everyone wants that life and income.





Well, not everyone. Just the people who had really high SAT scores in high school, really great grades in college and who learned how to play the game to their own advantage. These are not people who dreamed of being heroes, saving lives in the middle of the night, leaving their warm beds in the middle of the night and driving into the hospital where a distraught family awaits, holding the hand of their stricken mother.





No, the dream of some medical students is a big house, nice cars and maybe a boat.





Truth be told, that hero dream is not much to be found in medicine anywhere. Just look at the TV programs now if you want to see the screen writers' fantasies about the possibilities of a medical career.





And with the advent of shift work in the hospital, with hospital doctors now just employees and with doctors in the community no longer self employed in private practice, medicine is becoming or has become not an ennobling profession, but just a job.





Medical practice has been deconstructed into its parts: Much of it is now being done by nurse practitioners, "procedurealists" , laceration technicians, physicians' assistants and other people who never went to medical school but took a short cut to the white coat and the stethoscope.





Not all of this is bad, but none of it saved money to the total system and the important part of medicine, which never paid well, is now often not done at all. That's the part where you listen to a patient's story, told in a fractured way by a person who does not have a clue what may be relevant and you tease out a coherent whole which tells you what test to order and to which specialist or for what procedure to send the patient.





One thing which looks pretty clear is the economists who do medical economics at Princeton, or MIT or Harvard or Chicago have no idea which rock to look under. Their approach, their tools are simply incapable of finding the truth, or any meaningful answers. They simply do not know how to do ward rounds and to gather the right information or to organize it into a meaningful analysis.

 

Survivor Resentment

A long article in the New York Times today about a psychiatrist who had to give up the practice of psychoanalyst and shift to the practice of pushing psychotropic medications. He went from seeing ten patients a day to forty and he feels unfulfilled, says he hardly knows his patients, can hardly remember their names now. Years ago, he knew them in some ways better than their own spouses and lovers. Now, he is "efficient."

Of course, no law required him to give up the aspect of his practice which he found most spiritually rewarding: It was financial forces. Talk therapy was devalued, in part because a psychiatric social worker with a masters degree two years out of college could do what he was doing with talk therapy, at least as far as the insurance companies are concerned. He could have studied with Sigmund Freud hisownself, undergone  ten years of psychotherapy himself, written his PhD thesis at Harvard, after two years as a Rhodes Scholar at Oxford and authored the standard textbook of psychotherapy--none of those indicators of quality would matter to the insurance companies, or, for that matter to the American Board of Psychiatry which makes its living "certifying" psychiatrists and psychoanalysts.

So that is one of the many effects of a commercial system of medical care: Quality is that thing which shines with a light not perceptible by computers, bean counters or  vice presidents of corporate America.  Price is the thing.

Not that I or many of those who traveled with me through medical school, internship, residency and fellowship training have much sympathy for those who opted out of what we considered real medicine for the pseudo science of psychiatry.  We considered those people, who went into psychiatry after medical school the worst mistakes the medical school had made. Gave away the glittering prize of a place in the medical school class to someone who realized, somewhere along the four years, that he (or she) had made a big mistake and he didn't want to do medicine after all. That place could have been given to an orthopedic surgeon, a heart surgeon, a neurosurgeon, a pediatrician, a cardiologist, endocrinologist, rheumatologist, to, in short, a real doctor.

And it was not a little galling to see psychiatrists earning tons of money so easily, while people who went into the aforementioned specialties struggled. The psychiatrist in private practice was burdened with almost no overhead. Typically, they could rent a one or two room office, and they may not even need the expense of a secretary--an answering machine could do. They often admitted no patients to hospitals, did not work weekends and took no real on call at night. They had it easy. So every dollar they charged the patient was virtually all profit. For the other specialists, overhead ate up at least half of the gross income.

Which is not say psychiatrists are unnecessary or that psychiatry is not an important part of medicine dealing with important diseases.

My medical school class confronted the department of psychiatry at our medical school and refused to do the psychiatry rotation. We had read a book by Thomas Szaz, The Myth Of Mental Illness. So we were very well informed and we knew mental illness was just a convenient way of putting away inconvenient or obstreperous people. 

Astonishing, the chairman of the department at our very conservative and very upper crust medical school on the chic Upper East Side of Manhattan, listened quietly to all these rants from the students and, once they had finished, he said, with a sly smile. "Okay, I'll make you a deal. You have an eight week rotation of psychiatry scheduled for your third year. Just go to the psychiatric wards and observe for two weeks. Then come back here and we'll all meet again. If you still think, after two weeks of observing the patients on these wards we have simply made up a disease, that mental illness is just a myth, then you can have the next six weeks off, with my blessing. Go to Aruba, wherever. You'll get full credit for having completed all we expect of you in the department of psychiatry."

Of course, after three days of watching people with real big time depression, of talking with patients who afflicted by what was then called "manic/depressive illness" (now bipolar) or interviewing patients with schizophrenia who were hearing voices, not one of the ninety students in our class took the Aruba option. 

We were all humbled. No second meeting was necessary. We simply went back to the wards and watched and learned and got even more humble, seeing what those diseases were like, what they did to people, and how difficult the job of those psychiatrists really was.

Not that we were ready to embrace psychiatrists unreservedly. When we were in housestaff training, psychiatrists typically were not stand up guys: We had a patient staring out a ninth floor window at the end of the ward hallway, looking longingly at the sidewalk below, with a nurse and a medical student right there with her to prevent her from leaping out, and the psychiatric residents refused to come to the ward and do a consult.

That, in fact, was the trouble with The House of God a widely read novel about a medical internship at the Beth Israel Hospital in Boston.  After describing in detail the dehumanizing aspects of medical internship, that process by which caring human beings are transformed into dispassionate human beings who are capable of standing fast and not flinching when people who they like are going rapidly down the tubes, each of the real, sensitive, human beings in The House of God, opts out for psychiatry, as if that were the only consconable option for a real, sensitive human being. It was as if every member of Easy Company in Band of Brothers had deserted or simply refused to fight any more and been shipped back to England. None of them would have then liberated a concentration camp. But I digress.

And there are psychiatrists and psychiatrists.

One of the best psychiatrists I ever saw was that woman who "treated" Tony Soprano. That fictional show illuminated for me something I never saw in medical school--the possibility of a really insightful human being helping another human being to take steps toward a more meaningful and livable life.

Among real psychiatrists, my prize goes to the psychiatrist who had the unfortunate duty of having to spend an hour with six medical residents after we had been up all night on call with desperately ill patients on the intensive care units, the cancer wards. We had to spend that hour because the American Board of Internal Medicine required we have a certain number of hours of "psychiatric training."  Like virtually everything else about the Board, we considered this a stupid politically correct thing with no real value to insuring quality of medical training.

Oddly, though, in this one case, it did not work out that way.

The psychiatrist came in a little late, wearing a splendid tweed jacket and a spotless silk tie, freshly pressed shirt and there we sat, blood spattered, urine stained, smears of feces, vomit and dirt of unknown origins despoiling our white tunics and uniform slacks. Some of us fiddled with reflex hammers, others snapped their rubber tourniquets idly, and all of us looked unhappy about having to spend an our with this rear eschelon shrink when what we were aching to do was to go home to shower, to bed, to crash for an hour before we had to be back on the wards.

He looked around and asked what rotations we were on and we told him, one by one: intensive care unit,  Emergency Room, cardiac care unit, oncology (cancer) ward.  And he asked, idly, innocently, "See anybody die last night?" Actually, we all had, each and every one of us.

"What," he asked calmly, "Would it mean to you to learn you were going to die today? I mean, once you got past the disbelief, the anger, the rest of all that. What would it mean to you?"

And that's when it got really interesting. That's when the three guys, guys I thought I knew, who had kids, each one said, "It would mean I'd never get to see my kids grow up."

I knew these guys had kids, of course, But I almost never saw the kids. Sometimes, in a playground near the housestaff housing building, I'd see kids but I never really connected any of these kids with my friends, these band of brothers who I knew at the hospital. They couldn't have seen much of their kids, given our hours. I suppose, when they got home they could look at their kids sleeping.

Those, who like me, were not even married and were more concerned with who the next young lovely to warm our beds might be, we all said something to the effect that life had not really yet begun. We had been in school and training for something our whole lives. If we died today, we'd have missed actually having really lived.

So we did get something out of that hour, no thanks to the Board. We just happened to have lucked into a psychiatrist who knew where we had been.

I often wonder what my buddies would say if we were reassembled, about all the nurse practitioners doing primary care medicine who never had to go through what we went through on those wards, about all the "Physicians' Assistants" who see primary care patients, assist in surgery who never had to suffer through organic chemistry, physics, calculus and comparative anatomy--all those ridiculous courses which helped not one iota in learning anything which really mattered in medical school, but we had to do well enough to survive the elimination derby just to get to medical school, just to have the chance to claim a place in medical school so we could then compete for a place in a residency and then a fellowship program where we could stay up all night for years.

What would it mean to you to be told, well now a days, you don't have to do that to practice medicine or surgery?

I've thought about that a lot.

For now at least, I've come to the place where I'm saying, I didn't need to go through all that. And it was pretty awful at times. But in the end, I was lucky to have had the experience. It really was an honor and a privilege, in an odd sort of way.  I mean, nobody would say he's grateful to have had the experience of an artillery bombardment. But once he has, well, it makes him appreciate life just that much more.