Missing Medicine

Work has been getting me down as of late. It was a few short years ago when I was interviewing for medical school. I sat before a committee explaining why I wanted to be a doctor. I wanted to help sick people get better. In whatever creative way you say it, in essence, this is why people should be doctors. Instead I find year after year the patient less of a priority in the modern medical culture. We talk about evidence medicine and studies. We take board exams meant to be some sort of bar that we need to pass to prove we know the right things to do. Yet day in and day out I see these rules ignored, replaced instead by defensive medicine, lazy medicine, or just plain greed. It seems these days I hear more about the “cost” of things as opposed to the “right” thing medically to do. Before a patient is even in the system there is talk about their discharge planning and length of stay. Even taking a basic medical history is eroding away. Why take a history when you ask a consultant to solve a problem for you. I look at new trainees and many seem to be glorified secretaries. The top priority often appears to be writing a note and discharging a patient.

I often wonder what a hospital would look like if you put perfect strangers in there instead of doctors. Say for instance you took a stranger and said you are responsible for these 10 patients. Go! What would happen? I imagine the stranger would talk to the patient, noting their complaints. This person has belly pain. I better call the stomach doctor. This person has chest pain. I better call the heart doctor. Is this too far from what many actual doctors do these days? Perhaps it is a culture of defensive medicine or maybe it is just plain laziness. There are countless times when doctors fail to take even a basic history. My favorite is a person referred to cardiology clinic for left wrist pain. He sprained his wrist but no one bothered to take an actual history. They heard left upper extremity pain and sent them to the cardiologist. Sometimes chest pain can radiate down the left arm. A cursory 30 second conversation with the patient revealed this was certainly not cardiac.

Perhaps most bothersome is the culture change from a patient-centric to a business centric/shift based one. I will never forget a meeting in which I was arguing how defibrillators should be mandated on every floor. Someone promptly told me, we can’t afford that. There was no talk about the actual medical necessity, no talk about how we were no better than your average train station if someones heart were to stop on such floors. It clearly showed me how pervasive this culture of business replacing medicine has become.

Also, like a business, medicine has turned into a shift-based model. The future seems to be more and more of you being a patient in a hospital system as opposed to being a patient of a particular doctor. Private practices are being bought up by large hospital systems. The reason is simple. By consolidating, these systems can pay doctors less and be in a better bargaining position to get better pay from insurance companies. It seems inevitable that with a more corporate culture the doctor patient relationship will suffer. I don’t know about others but that relationship is a big reason why I wanted to be a doctor. The role of the doctor gets reduced. A doctor spends a decade training, learning what medicine to give for a particular condition only to not be able to give that medication because a particular insurance company on a particular day does not find it profitable. The doctor then has to take time out of her busy day to call and justify this decision to a secretary on the other end. The ludicrousness of this become apparent if you think of other professions having to do the same thing. A lawyer is about to give cross examine and is stopped, “Sorry in order to ask that question you have to get it prior approved by calling this number.” The lawyer would then call that number and for the next 30 min be bounced around before having to fax a form and try to get permission to use that question. If this example seems ridiculous it is far more ridiculous when people’s live and well being depends on such asinine protocols.

I guess I find myself longing for things to change. I miss medicine.

Tied

It has been way too long since I’ve written on this blog and for no over reason besides the fact that I’ve been exhausted. I’ve been a doctor going on four years now and I can’t help but feel that it isn’t quite what I expected. American society is in a debate right now as to what our health care system should look like. The reality of finite resources has finally come into play as the economy has taken a turn. We have to ask the fundamental question: how do we treat an ever aging population with more expensive treatment options given finite resources?

When I think back to graduating from medical school I was giddy with excitement. I had matched in my top program for residency was moving to Manhattan for residency, all was well. There was a sense of inspiration hope. As I’ve gone through training however, especially over the past year now in fellowship I realize this field I had gone into, the field I loved, was changing in a way that was turning me off.

I went to medical school to learn how to help treat sick people. Yet a good portion, if not all my time now is thinking about how to defensively justify my actions as to not get sued, save money, appease a particular physician’s style of practice. If I had wanted so much political and legal formulation I would have gone into politics.

The sad fact is while I still like the field I’m in, I no longer love it, mainly because it has warped into a paranoid distortion of an ideal I had when I graduated. I operate with one hand tied behind my back, one eye closed. Frustrations of physicians are never addressed in a meaningful way. Medical records are a key example. Advancements in informatics appears to be trickle last into medicine. At work I use computers over a decade old without a real medical records system, and only this past month did we move beyond VHS tapes for some of our imaging. This is how most of the country’s medical records are and it is insulting to patients and physicians. It is one of the many reasons why I am so frustrated. Without information I am driving blind and have to recreate the wheel.

It is 2011 and we still rely on FAX machines to transmit medical information, if we can even find them. Yes, fax machines. Think about that the next time you update your Facebook status on your mobile phone while transmitting funds from your bank account, and listening to your iPod. Medicine is in the stone age. When talk of online records came the public cried about how this would not be secure; paranoia. Perhaps they didn’t know of how things are really done. You can go to Domino’s pizza and get minute to minute information on the various stages your pizza is to completion yet I can’t find old records on a patient who is in a hospital a few blocks down the street, or even at my own hospital for that matter. Yet, there is no public outcry on this, probably because people don’t know. And yes people have died simply because we don’t have a coherent way to transmit information.

Then there is the systematic character assassination of doctors. The medical profession has been demonized, as selfish doctors doing too many procedures, charging too much. I am the first to say, yes there are bad doctors. But in fact doctor’s compensation has taken a huge hit in an attempt to curb this spending increase. Yet no one really questions why we spend so much. Is it perhaps because doctors are forced to do so much because if they didn’t they would be at risk of being sued? Is it because in the US our culture demands the maximum amount of care regardless of prognosis? Is it because we have failed to ration resources? These are the real issues.

I find medicine fascinating. The human body is remarkable beyond belief, a miracle that even the best engineers could not begin to comprehend. I get a high from understanding how it works, how it goes wrong, and most importantly how to fix it. It gives me so much joy when a patient smiles at me, says thank you, gets better. I’m tired. I’ve worked countless days and nights. But it was worth it. I’ve saved lives. I want to love this field again. I just need someone to untie my hands from behind my back.

Life in the Spin Cycle

This is my first medical documentary. It was the culmination of a two year effort of filming. We made a film trying to give a brief glimpse into what it is like to be on dialysis.

My Father on BBC World News

A well deserved tribute to my dad and his long and prolific career.  The BBC joined by dad on his latest field day in Parma Idaho.  Watch the clip below.

Do No Harm

It was another sleepless night intern year.  I was called to bedside of a deathly ill old woman because her oxygen level was low despite being on the maximum amount of oxygen.  I pulled up her x-ray.  I squinted to figure out what I was looking out, in case it wasn’t obvious enough.  A massive white blob occupied nearly her entire chest cavity, it was cancer.  I knew where this was heading and immediately called the family.  I explained how her heart was going to stop because she was not getting enough oxygen and that if her heart did stop, trying to restart it would only be temporary.  The daughter stated that she wanted “everything” done.  She had just lost her father and couldn’t bare the guilt of her mother dying.  She instructed me to only do CPR and not put her mother on a breathing machine, something which made no clinical sense but by some law I had to do.  I tried to reason how this was futile but to no avail.  Any layman knows when your heart stops, you stop breathing.

For the next hour, I morbidly sat slumped in a chair in the woman’s room watching her monitor.  My eyes were heavy, I wanted so desperately to sleep and as soon as I found my eyelids falling I quickly looked up at the monitor.  I knew what was going to happen.  I knew what her heart would do.  I knew what I would have to do.  I knew the grim outcome.  My mind went back to a year earlier as I took that oath with a jubilant group of my friends and colleagues.  Do no harm.  Here I was, forced by a family member to do something completely medically futile.  Forced to ignore my clinical knowledge as a doctor, and like a foot soldier dictated by the medical legal complex  just do as told, not over-think my oath.

The blood pressure started to drop, the breathing mask bellowing air onto the face of this, frail ashen-grey woman.  I got up from my slumped position in the bed, and felt her neck, no pulse.  Like a good soldier I did the drill.  I yelled for the nurse, jumped on the bed.  Two hands together, I pushed on her chest.  The first press was followed by the crunch of ribs cracking, like someone breaking a bunch of celery stalks.  I turned to the nurse, “Push one of epi!”

“I can’t, I’m not a doctor”  The lawyers also forced her to do as  told, she technically wasn’t allowed to push the meds.  I stared her right in the eye.

“I’m right here.  Do it!”

A group of groggy eyed residents came in to help in the code.  As I hopelessly pressed on this woman’s chest I knew I was not allowed to put her on a breathing machine.  I knew even if I could that it would make no difference to her ultimate fate.  But in that moment I wasn’t a doctor, I was a cog in a machine stripped of power to act based on reason.

With each compression her frail body was jostling, eyes rolled back.  There was nothing and after three agonizing rounds of CPR it was over.  I left the room feeling sick.  I did my job like a good soldier, but it felt wrong even though I did everything right.  Hypoxia induced asystole with a code that was run like a textbook.

I called the daughter to tell her about her mother.

“I’m so sorry”

She quickly asked, “Did she suffer?”

I wanted to yell, to say how she forced me to torture this lady.  Did she not know what she instructed made no sense?  I actually had told her such before all this happened.  Yet she had lost her mother.  As much as I wanted to voice my frustration and tell her of the ribs I cracked, the pain I inflicted to no avail, I didn’t.  It was in that moment that I turned from a soldier back into a doctor, “A resuscitation is never easy.  We did all we could.  Would you like to come and see the body?”

“No.  Someone will come to pick it up shortly.”

I again refrained, mostly from shock.  How could someone not want to see their mother who just died.  It was then that I realized there were other forces at play: religion.  But who was I to judge.

The sun would shortly be coming up, and like a good soldier I went back to work trying to do no harm.

Gateway to the Hospital

The emergency room is a strange world. It’s both the best and worst of medicine all in one crazy area. In one room someone is getting impacted ear wax cleared from their ear, in another someone is being resuscitated after a cardiac arrest. Some people find their back pain was really a dissected aorta, others find that their back pain is a ticket to a few hours sleeping on a cot inside the hospital away from the cold NYC streets. The ER is the entryway to the hospital. Most people that end up in the hospital first have to go through the ER, “get processed” so to speak. It is also the safety net for the uninsured and those that don’t have access be it by choice or by circumstance (such as a closed clinic on the weekend). If there is one thing in my mind that is certain is that experience in the ER shows you the future of modern medicine and it is a grim one.

I have now worked in ERs on the west and east coast and they are all similar: bursting at the seams. Inevitably stretchers are lining the hallways as the ER gets put on “divert” meaning literally it is full. This is all under normal circumstances. There is no influenza epidemic, no massive plague, no terrorist attack. One can only imagine what would happen under those circumstances. The ER is about getting patients in and out as fast as is safely possible. Delaying may result in the next person getting sicker, or even dying. Yet, ultimately the ER is all about delay. Beds in nearly full hospitals are not ready. Patients wait hours, even days waiting for a bed to get admitted. This “wait” was what our non-nationalized system of medicine was supposed to be somewhat immune from. Consultants from various medical disciplines take hours and hours to see patients as they are stretched too thin. Yet those various disciplines are more competitive than ever to get into. You don’t see new medical schools popping up. You don’t see class sizes expanding even as demand for doctors increase.

The other day I had a 100 year old patient. He was a former doctor at the hospital. He had pneumonia. He was stable but far from well. He was throwing up left and right. The overworked nurses would get to him when they could but he had already soiled his clothes. His frail wife marched around trying to find out when he would get a bed. After all he had served for over 20 years at the hospital and here he was soiling his clothes and people were too overstretched. It was obvious she was becoming very exhausted. I went in the hall and stole a chair for her to sit on. What else could I do? It wasn’t as if I could magically make a bed open up. She came up to me, “You guys are fine but he served here for over 20 years, I never thought we would be treated like this.” I went over to his bed stretchers lining the hallways which were bursting at the seams. I stood in the center of a mass of stretches. I looked 360 degrees around me. They were all my patients. They seemed to all look at me: the women with anemia, the man with pneumonia, the lady with a shunt in her brain. They all had the same look on their face, that of exhaustion but I couldn’t help but think it wasn’t the exhaustion because it was 2AM in the morning. It was that same exhaustion I felt. Maybe it was frustration.

The other day as I was going to clinic for a meeting I ran into a man in the elevator who smiled at me “Hey you’re that doctor that took care of my wife. We’re here for the follow up appointment. ” He got off the elevator, “It’s nice seeing you.”

I love what I do but sometimes it feels like people don’t love each other and themselves. People lack insight into their disease, partially by their choice and partially by the fact that doctors cannot spend enough time with their patients as they are in such short supply for an ever aging population. If only it were about sore throats and coughs. It’s about people on dialysis, people with multiple stents, people with liver disease, people with med lists that have to be typed because who can remember 15, 20, 25 medications. I don’t understand society even though I see it at its most vulnerable. If a system is in such a dire state that if action is not taken it will collapse is it not society that should be compelled to fix it? If anything needs to be “bailed out” is it not this? Would doing so be any more “socialist” than funding banks that made poor decisions and coerced others in doing the same?

There is this notion of personal responsibility that many critics bring up with respect to people. I believe in this, to a point. Yes, many people by poor choices have caused or exacerbated their illness. There are people who took out loans when they did not have money. Fatty food is cheap, and loans by banks were cheap. It was their choice but it was other’s influence that had a large part in it. When the consequences of those actions come to fruition what do we do?

Is it not then a double standard when we chose to bail out one group and not the other? Have we not by our actions as a society put money as a higher cause to act on than our health? Is that the “choice” we are making? People have a responsibility for their actions, but as people in a society do we not have a responsibility to act to improve our society and help others make more sound decisions. Choice is not a simple a, b, c response. Doesn’t the 300lb man with diabetes know that white bread is bad for him? At first glance it is his “choice” that he eats white bread. But having been around enough people with disease I can tell you it is never that straightforward. That 300lb man may live in a certain section of Harlem where for wheat bread is nearly nowhere to be found. Then again maybe that same man has wheat bread and chooses not to eat it. This is despite the variable of mental illness which is much more prevalent than people can imagine. Is someone ravaged by depression, bi-polar, or dementia really making a “choice” that is the same “choice” as that of a mentally healthy person? Nonetheless at the end of the day if he spirals downward he will end up in the ER. There is no distinction between those that made poor choices and those that didn’t. He will sit right next to the 100 year old doctor. In making the assertion that you will chose to treat those who made the right choices and let those that made poor choices suffer, you are making a choice to judge without enough information. If in a court of law you have to prove beyond a shadow of a doubt is it different in a hospital? With such overburdened resources there is really no way to assess who made bad choices with appropriate options and access. That is the luxury of philosophers and those that aren’t on the frontlines. But every so often you will get a smile in an elevator that reminds you why you are on the front lines.

It’s a strange world indeed.

More than an Election

The past month and a half have been very busy.  I learned a lot, helped a lot of people.  Yet, I lost focus.  I lost balance.  I missed the voter registration in NYC so I didn’t get to vote, in an election that I wanted more than ever to vote in.

Over the past eight years I have been incredibly vocal about my disgust for how this country has been run.  I’ve traveled to numerous countries during this time and first hand have experienced how the image of the US has been tarnished.  I saw how misguided our leader’s world view was compared to what I actually saw with my own eyes.  I have seen a so called “conservative” who believed in the free market to solve all our problems resort to one of the largest government subsidies of all time and at the same time have his party call the opposition “Socialist”.  I have seen an economic crisis, two wars, and terrorism all in such a short period of time.  There were more than ample issues for candidates to debate about.  However, shortly after moving to NYC I realized that what was evolving was far beyond just “issues” in a campaign.

Working near the border of Harlem I get a tiny glimpse into the lives of people who come into our hospital.  As I walk to work every day and around the city invariably I see the numerous street vendors most with some form of Obama gear.  Pins, bumper stickers, Che-like images on T-shirts.  In the blistering sun and cold ice-like rain they are there selling and promoting.  People from all walks of life bought the stuff and wore it proudly  Day after day after day.  At construction sites I would hear blue-collar workers talking about Obama and why he was the guy to go for.  At the hospital nearly everyone I saw were anxious to cast their vote for Obama.  I saw young black teens on the subway, their bags sporting Obama pins.  I saw reggie artists with Che-like obama shirts.  Campaigners with Obama posters constantly patrolled the streets at all hours.  As election day came there was a sense in the air that something was different.  It was perhaps a superstitious sixth-sense feeling of something to come.  Despite my infinite frustration at myself I knew this was a day I was going to remember.

I went to Rockafellar Square.  Thousands of people lined up; a blue banner representing Obama towered over McCain.  Obama had 207 votes.  A white woman stood with a star poster welcoming Obama, the back of her head had an Obama mask on it.  The clock struck midnight and just like a lightning bold the blue banner shot up as the West coast came back big for Obama.  The large monitor had Obama on it and declared the next president.  The crowed exploded.  Years of anger, frustration, and loss of hope all came out in their chants.  “BUSH YOU’RE FIRED!  BUSH YOU’RE FIRED!”

That transitioned to “OBAMA!  OBAMA!”

A pause…

“USA! USA! USA!”

A black woman came in, her eyes in total shock imbracing the white woman with the Obama mask. “Thank you.  I’m fifty years old.  Thank you for everything!”  In Harlem people danced in the streets.  Tears of joy were shed.  I couldn’t help but become tearful.  It wasn’t about the economy, the war, or the environment.  It wasn’t about Bush.  It was about something that couldn’t be put into words.  It was about those voters who voted for the first time.  It was about the poor black kids in Harlem that wanted to believe in the impossible.  It was a movement.

For me personally it was a wake-up call to find balance and take care of things that are important no matter how busy I am because it does matter.  I had a renewed sense in a country I had been so cynical about.  It was an American “reboot.”  No matter how tempting it is to be cynical this election showed an alternative to the fear and cynicism we have become so accustomed to.  And as far as the challenges we face and whether we can address them: yes we can, yes we did, and yes we will.