Archives for posts with tag: hospitals

In recent months, two stories of mine, both having to do with medicine, healing, and Baltimore, have appeared in two literary journals.683788737

In “A Letter for You,” appearing in Gravel, a white doctor tries to orient himself with regard to his African-American patients.

In the first issue of Dryland, a new litmag from LA, you can read my story “Pain and the Machine,” in which a floor buffer chases a janitor down the hall.

I’d love to hear your reactions to these.

This week, I covered for one of the chief residents. I was the attending physician for about 25 patients in the hospital during the space of a few days. On one of those days, I still had scheduled my regular outpatient clinic; the entire day became a way to experience the contradictions inherent in the practice of medicine, crossing the street again and again between the hospital and my clinic like a shuttle on a loom.

How many contradictions, or rather, pairings that we see as contradictions, confronted me with each patient I saw, comparing in my mind the medicine I practice every day in clinic with the kind of health care delivered in our hospitals!images

  • Providing each person the care that works for her uniquely, while uniformly assuring best practices for safety to hundreds of patients at a time.
    Getting the tests and treatments that are needed as fast as possible, while deliberating appropriately on the evidence base of every intervention.
    Treating pain — but acknowledging the dangers of opiate addiction.
    Enabling the patient to make decisions, while recognizing they need the support of a treatment team in an alienating and scary environment.
    Discharging as soon as medically possible, while aiding the patient in their convalescence.
    Hewing to principles of safety and organizational efficiency, while being unafraid to venture out of the box when changed situations demand it.

How can we treat patients while on the very knife-edge of these contradictions? Treating both inpatients and outpatients makes me more sensitive to the edge, but I’m not sure I can dance any better….yet.

A patient writes (and I share with her permission):

On the night of April 20 after dinner I felt a great pain in my left shoulder and up along my neck. Chills and the pain prevented my sleeping. This pattern continued, severely, along with utter exhaustion by 3-4 PM every day and no appetite, through the 28th, while the pain began to extend into my left rib area, under my left breast. The 3rd night I remembered I had the 800-mg ibuprofen pills that Dr. B had given me, which I began taking every night thereafter, and it helped me sleep somewhat better. While all these symptoms persisted, after 4-5 days the overall pain began to slowly decrease a bit. On April 25, with my brother’s insistence, I went to the doctor. I was assigned to a Dr. A, who is working under Dr. D. She was worried that I might have had a heart attack, though we have no heart problems in my family. The nurse administered an electrocardiogram test, which turned out normal. Dr. D (whom I haven’t seen in 15 years or so!) also examined me. They had me get a chest x-ray and a blood test (for kidneys?) Dr. A phoned me today saying that these uncovered no problems, though a couple of little irregularities which she said are too minor to bother about. It was these that prompted me to have her send you the results, and this note of mine will give you their context.

All that being fine, now I have to return, on my own, to my original theory of what caused all this pain, sleeplessness and weakness. From early on I suspected that in working assiduously on the computer all day of April 19 and 20, I was unconsciously leaning strongly on my lower left arm and elbow – not having the perfect ergonomic set up for working on the computer. Nothing like this has ever happened to me before, though periodically I have tried to deal with the seemingly incorrigible constraints limiting my desk and desk-chair arrangement for using the computer. Though when I saw the doctors on April 25 I told them this admittedly-lay diagnosis, it didn’t interest them in the least, but now I”m pretty sure it explains what I experienced – though still not the complexity and severity of it.

Since you’re interested in the patient-doctor relationship, I thought I’d share with you my reflections on this happy-ending experience. (Though your book does help us a lot to understand the physician’s point of view). What I observed is that these highly trained physicians – both in “general internal medicine” – either weren’t interested in the “muscles and nerves” dimensions I had first proposed as a diagnosis, or else they didn’t have the basic knowledge or expertise to deal with what I related. I realize that they went for the potentially-fatal possibilities like heart, lung, kidney. Good. That’s reassuring. But even when I asked, before they dismissed me, what they would suggest about the severe pain and other symptoms, in the event that the tests showed nothing serious — even when I wanted to bring them back to the original problem, which still persisted – they offered no ideas about what might have caused all that I was going through, much less offered any details about how it might have happened, or guidance about what to do. And today when Dr. A phoned with the results, if I had not asked her specifically, she would not have addressed the problem itself. (She was not aware the pain had declined) When I did ask, she advised me to talk to a physical therapist, which I will.

Despite your excellent clarifications in your book, and re-orienting the patient’s perspective, we laypeople aren’t as compartmentalized in trying to think through our medical problems as you doctors are, though of course most of us are aware that the medical profession has various specializations. In my little episode, I thought that in the end the doctors I consulted would remember that I had come to them with a severe pain, and that they would eventually come back to addressing that. They seem very relieved that the worst hadn’t happened; but… hello? what about “me”? okay, if my heart, lungs and kidneys are okay, but what do you have to say about my pain and what might have caused it? and what should I do about it? I guess my original expectations in going to them were unrealistic.

Today, really for the first time, I feel fine. No pains. I hope I haven’t wasted your time with this little narrative, which I have not written out of frustration, but as part of our common interest in the “patient-doctor” interface.

I just got back from the annual meeting of the Society of General Internal Medicine. You should check out all the tweets.


Below is a poster that I presented there on how doctors and patients communicate in the hospital. Though the findings are limited and preliminary, I would welcome your comments!

How do patients and doctors communicate in the hospital? Assessing shared decision making and interpersonal…

I covered one of the chief residents in our hospital for two days this past week, seeing more than 40 patients in total. My off-the-cuff remarks on Facebook still apply:

Twenty-two inpatients later, it is time once again to declare my awe and admiration for all who do this work daily: hospitalists, housestaff, nurses, techs, custodial staff (et al., et al.). And, of course, the patients who are – on the other side of the hospital mirror – working harder, in their way, than all of us.

What’s more, I was struck – not for the first time – by the differences between the hospital and clinic, not just in tone, atmosphere, communication, and pace, but in how those things affect medical thinking and decision making.

I am not talking about critical care or emergency medicine, nor about “codes” (cardiac resuscitation) – merely because I do not participate in such care regularly. But I think my observations might still apply.

Simply put, the hospital operates under the assumption that things have to move faster. That tempo, I believe, encourages a certain frame of mind: we should treat, do, test. People are sick, we want to make them better, and lab tests and interventions are an avenue to this.

You already see where I’m going, because – if you know me or my blog – you know my bias. If anything, I think we tend to over-order as a health care system….and the scientific literature bears me out.

What would it mean to apply evidence-based medicine to hospital care, in a thorough-going fashion? I mostly do outpatient medicine, and guarantee you that I assume no superiority for the application of EBM in that realm: no, much of what we do in clinic is still based on intuition, externalities, unsupported lore, personal preference (not the patient’s, God forbid, but our own as doctors), or some other blend of bias and conviction.

Would it be harder in the hospital to take stock? Would workflow be disrupted?

Or is it just that I am unaccustomed to the hospital, and things are really changing in that direction? What do you think?

Most of the time I take care of patients in the clinic, but I regularly admit patients to the hospital as well. I try and notice what makes me uncomfortable when I see them there. (Which is probably not as completely or acutely noticed by me as by the patient – but, hey, you take what you can get on this blog. Obviously, there are no shortage of patient blogs to read as well.)

No one knows anything. The attending – me – doesn’t know discharge time because it depends on when the meds are filled and the appointments are made. The patient doesn’t know their discharge time because they are under the mistaken impression the exact time is up to me.

Decisions are made elsewhere. The patient’s wife, who is on top of things and asks impressively detailed questions which have improved care for her husband, asks what a certain specialty service is going to do about a procedure. I don’t know, and I’ll ask them. But any decisions they make are not going to be done in the room, while talking to the patient and his wife. They’ll be made in some corridor somewhere, and then transmitted to me by page or phone. Everything gets to the patient and their family third-hand.

The endpoint isn’t clear. We try to identify, at the beginning of the admission, what is the goal for discharge, but when the active issues change, as they have many times in this case, the patient can find themselves in the hospital for longer than they had expected.

Outpatient versus inpatient. The patient is understandably concerned about missing the clinic appointments he can’t keep because he’s cooped up here in the hospital. He wants to know if those services can come by. No, I start to say, by instinct, because they deal in the hospital with urgent or severe matters. But then I thought: couldn’t we do it that way after all? We do counsel smoking cessation, and do other preventive services or counseling, for patients who might not get them any other way.

An esteemed senior physician who I knew in New York says that every patient is an opportunity to do research, i.e. learn about the course of disease. Whenever I see a patient in the hospital, it feels like health services research in miniature. This is what the hospital is like: bewildering, inefficient, and at cross-purposes with itself.

No false modesty here: we have a great team, and the gentleman is getting better! Not without, though, teaching us important lessons in efficiency, patient-centeredness, and humility.

Cross posted at Talking To Your Doctor, the blog.

In a recent article in the New York Times, the prolific Danielle Ofri makes the point that inpatient and outpatient medicine are so different as to be on different planets. She’s right, of course. In the hospital, illness is more acute and everything needs to be done faster. More resources are used. Life or death can often hang on every day’s decisions. In the clinic, most things are slowly developing, many things get better on their own, and decisions are less weighty.

Or that’s what we think. From a patient’s point of view, the hospital and the clinic share many similarities:
1. The language can be bewildering.
2. No one spends enough time.
3. Decisions are made without asking you.
4. You are given medications without full information or the chance to say no.
5. People process you without introducing themselves.
6. You are made to dress and undress at the drop of a hat.
7. Everything costs too much, and it’s hard to figure out why.
8. There’s nowhere to put your kids.
9. If you speak another language, you have to wait for an interpreter – or sometimes you don’t get one at all.
10. You are too confused, or sick, to think straight, but sometimes you are expected to share in the decision as if you are fully empowered.
11. You wait and wait for your questions to be answered.

 

Ofri’s point is that, once upon a time, the same doctor would see patients in the hospital and in the office. Nowadays, it’s most common for special doctors to see patients in the hospital, and other doctors, of the outpatient variety, to see them outside. The technical requirements of the two environments are two different for one doctor to be able to deliver good care in both.

What does it tell us, though, if the experience of the patient is similar in important ways in the two environments? Does it mean that the right kind of doctor can provide superior care to patients in the hospital and the office? Does it mean the care needs to be reshaped, in equally serious fashion, in both places? What do you think?

Cross-posted to the blog at Talking To Your Doctor.

Let’s share the glad tidings: Johns Hopkins is again ranked as the number-one hospital in all the land. I’ve written about this before, sharing my misgivings about ranking hospitals. What is the methodology? How sensitive is the ranking to random error, bias, and qualities of hospitals that have nothing whatsoever to do with their – quality, like reputation? What are we supposed to do with that information, who really uses it, and do they get better care as a result?

There are enough misgiving here to fill several chapters of a book, and in fact one chapter of mine is devoted to them. But the problem with measuring extends far past the ranking of hospitals. Doctors are being ranked this way, too, with the idea that public reporting of such information will help people make better choices about their health.

At the same time, many are trying to urge our health care system towards greater patient-centeredness. Various research teams are developing measures to quantify how well a given visit with a physician enables shared decision making on the part of the patient-doctor pair.

So, when presented with an array of various numbers – the rank of the hospital; the quality of the doctor; and the patient-centeredness of the practice – which one should the patient choose? Do we ask patients, as a whole, which ranking they find more important? Is each person to mix up a batch of numbers to find whatever aggregate satisfies their preference?

These are big questions. As I outline in my book, there is evidence that precious few patients or doctors actually use these rankings. Perhaps if we include patient-centeredness in the mix, and automatically generate a weighted average (or some other statistical combination of measures) that corresponds to patients’ preferences, people will feel like they are getting the best doctor they can find. That would be something to truly celebrate.

Cross-posted at the  Talking To Your Doctor blog. 

1. Should I take an aspirin?

2. Should I take a medication for osteoporosis?

3. How often should I get a DEXA scan?

4. Should I see a specialist about this?

5. What’s the best test to keep me from getting cancer?

6. Can you write me a prescription for an antibiotic?

7. Can’t I just get an MRI?

8. What’s the difference between you and a family medicine doctor?

9. What diet can help me live longer?

10. Can’t you just order me some baseline bloodwork?

And a bonus:

11. Why is your hospital better than any other?

Johns Hopkins has gotten itself some new hospital buildings, and I am conflicted. It’s a beautiful building, including a new children’s hospital and sparkling, still plastic-wrapped facilities for many, many things. But I’m not sure how often I’ll make my way there.After five years of construction the new, $1.1 billion Johns Hopkins Hospital is about to open.

That’s because internal medicine has no space there (I mean internal medicine as a primary field; cardiology and gastroenterology certainly do). This is not surprising – we are not a money-making subfield. The modern hospital, after all, is built on sexy specialties, not the longitudinal spadework of the primary care provider. When I admit my patients to the hospital, they will be in the “old” buildings, and when I see my patients in the clinic, I will keep seeing them where I do now – in what is admittedly not an “old” building at all, since it was built in the long-ago aughts.

I am also conflicted about the new building’s presence within our East Baltimore community, with which our relationship has not been … uncomplicated. An architect friend of mine, native to and knowledgeable about Baltimore, remarked that my institution presents a closed face to the city with its buildings. There is no streetscape, nothing beyond the blank glass. The main medical campus gets lively only when people get outside, whether it’s to sit in the sun on the grass in front of the monumental Dome or buy something at the farmer’s market. Thinking back to the other medical campus I trained at, NYU/Bellevue, I remember the energy that poured out from the street into the hospital lobby, and how animating it was.

The new hospital building is shut off too. Yes, it is outfitted with restaurants and cafes aplenty, but I don’t know which of our neighbors will eat there or feel comfortable walking in. Maybe that’s an unreasonable thing to expect from a hospital, but I hoped we could do better.