Sunday, October 9, 2016

The Importance of Medical Judgement - Part I

Would you rather that your doctor have excellent medical knowledge or medical judgment?  Answer this question before reading on.

Patients are drawn to doctors and medical facilities who boast ‘cutting edge’ medical knowledge and techniques.  Medical judgement, which is much more important in my view, is barely mentioned. 

Good doctors have great knowledge, but great doctors have superb judgment.  Consider the following vignette that I hope illustrates why judgement means more than knowledge.

A patient is comes to the emergency room with abdominal pain.  The physician refers him to two different physicians, Dr. Knowledge and Dr. Judgment.  Which of these physicians would you rather see?

Is the gallbladder the culprit here?

Dr. Knowledge:  I recommend that your gallbladder be removed.  I have trained in advanced robotic surgery which leaves only one very small scar.  My complication rate is extremely low.  Our operating room team is excellent.  I am the only surgeon in the hospital who is credentialed in robotic surgery.

If you visited only Dr. Knowledge, then you would likely be very impressed with his credentials and would schedule the surgery with great confidence that you would receive excellent care.  If you had family members with you, your conversation afterwards would mention how lucky you were to fall into the hands of such a talented surgeon.  Before you belly up to the scalpel, let’s hear from Dr. Judgement.

Dr. Judgment:  After listening to your medical history and examining you, I don’t think that your gallbladder is responsible.  While I’m not certain what caused your pain, I do not think that you should have surgery and remove an organ that is an innocent bystander.  Since you’re feeling better now, let’s just keep an eye on you for now.   I’ll see you in a month.  If the pain returns, then call me right away.

I know which of these doctors I would want as my doctor.  Medical knowledge, however, has a lot more sizzle than medical judgment.  Look and listen to the advertisements from our area health care institutions.  Knowledge sells.  Do any of these sound familiar?

·       Our orthopedists can make your back pain go away with a painless treatment that takes only 1 hour.
·       Make obesity history.  Make our bariatric surgery team, your team.
·       Our state-of-the-art oncologists specialize in giving second opinions.  You deserve state-of-the-art care.  Call us.

Check in next week for Part II on why I think a physician with good judgement is a better doctor than Dr. Mensa.

Sunday, October 2, 2016

Is Your Doctor Out of Date?

Years ago, I was having dinner with 2 members of The Cleveland Orchestra, one of the finest orchestras in the world.  I asked them, with my kids present, how much time they devoted to their craft.  As many parents know, getting kids to commit to practicing a musical instrument is about as easy as splitting the atom in your garage.  The musicians told us how much time they practiced, which was mind boggling, as one would expect.  Any artist, athlete, Green Beret or similar professional, has to demonstrate extraordinary commitment to maintain a superlative level of excellence and preparedness.

I asked one of the musicians, the violinist, how long he could refrain from playing his instrument before he noted some professional slippage.  Guess your answer.   At the end of this post, I will relate his reply.

How many hours are enough?

How long can you be away from your job before your performance ebbs?For most of us, we can take weeks or longer on holiday and return back to our positions seamlessly. 

A few examples.
  • Politicians return to Congress after long breaks and lose not a whit of their capacity for obfuscation and duplicity.
  • New York City cab drivers return from vacation and can still take you on a ride of terror to any destination.
  • An airline customer service representative a few continents away maintains state-of-the-art client service even after a month away from her cubicle.
What about doctors?  What about gastroenterologists?

 Yes, I do take vacations, but most of them are long weekends.  It’s rare that I take even a week off. Perhaps, the reason why I maintain such a keen colonoscopic edge is because my absences are brief.  If I took a sabbatical for 6 months, would I be rusty when I approached my first rectum on my return? 

Now, manipulating a colonoscopy when I bringing light into a dark world is not exactly the same as playing violin in the Cleveland orchestra.  I’ll leave it to the reader to contemplate which of these activities demands more skill. 

Seriously, do physicians lose their cognitive and procedural skills after an absence?  I’m not sure this has been tested, but I believe the question is a reasonable one for patients to consider.  Hospitals will track volume of surgeries from specific surgeons, but a busy surgeon could meet the yearly threshold, and still take several months off.  Should a patient who is to undergo a cardiac bypass or a colonoscopy after the physician has been away for a few months be concerned? 

Is medicine like riding a bicycle that one can do well after a hiatus of years or more?  Or should doctors who have been off the bike for a while put some training wheels back on. 

Consider this the next time you are hearing music from a master musician in a concert hall.  One thing is for certain.  He hasn’t been loafing on the beach.  My musician friend told me that if he is separated from his instrument for 3 days, he can hear the difference even if we couldn't.  

Sunday, September 25, 2016

Nursing Staffing Levels Threaten Patient Care

On the day that I penned this post, I rounded at our community hospital.   My first patient was in the step-down unit, which houses patients who are too ill for the regular hospital floor.   I spoke to the nurse in order to be briefed on my patient’s status.  I learned that this nurse was assigned 6 patients to care for – an absurd patient volume for a step-down unit.  “Why so many patients?” I asked.  She explained that some nurses called off work and the patients had to be spread around among the existing nurses.

This occurs every day in every hospital in the country.  Nurses are routinely required to care for more patients than they should because there is a nursing shortage on a particular day.  Why do hospital administrators allow this to happen?  If any are reading this post, I invite your response.  Enlighten us.  When a nurse is overburdened, how do you think this affects quality of care and nursing morale?

I suppose it saves a few bucks on payroll, but this strikes me as very short term gain that risks medical and financial consequences.   Providing high quality medical care can’t be a rushed effort.  If a nurse’s job description increases by 30%, do you think the quality of care and patient/family satisfaction won’t decline?   Don’t administrators fear the risk of medical errors from overworked nurses?  Would any of them like to be patients under these circumstances?

Nurses Need Help

Nurses have confided to me for years how demoralized they are that no one speaks for them.  Instead of watching their backs, they often feel that they are stabbed in the back.

I do not have warm feelings for labor unions and I support right to work initiatives.  But, when I see what nurses endure and the lack of support that they receive, I would support them if they moved to organize.

If a 3rd grade teacher is ill, we expect a substitute teacher to be called in.  The third graders are not simply herded into another classroom expecting one teacher to handle a double load. 
Many of us today are asked to do more with less.  Teachers, law enforcement, businessmen and government program administrators know this well.  At some point, you aren’t cutting fat anymore, but are slicing into bone. We are not taking proper care of those who have dedicated their lives to care for us.  Who will heal the healers?

Sunday, September 18, 2016

Why I'm Against Medical Marijuana

I have already opined on my disapproval of a medical marijuana law recently passed in Ohio.  Once of my points in that piece is that I did not want legislators making medical decisions for us.  They can’t even do their own jobs.

I am not against medical marijuana; I am for science.  The currency of determining the safety and efficacy of a medicine should be medical evidence, not faith, hope or belief.

Marijuana is a Drug Enforcement Agency (DEA) Schedule 1 drug, alongside heroin, LSD and Ecstasy.  I realize this seems odd since most of us do not believe that marijuana has the health or addictive risks of the other agents on the list.  It doesn’t.  But, danger is not the only criteria used in determining which category a drug belongs in, a point often misunderstood or ignored by medical marijuana enthusiasts.  An important criterion of Schedule 1 drugs is that they are deemed to have no proven medical use.

The federal government recently affirmed marijuana’s Schedule 1 status, which disappointed those who argue that this agent is the panacea, or at least an effective treatment, for dozens of ailments.  The government disagreed.  It reviewed several hundred medical studies and only identified 11 of them that were of sufficient scientific quality worthy of consideration.  None of them demonstrated a salutary effect of marijuana.

DEA Holds Firm 

An advocate of medical marijuana use was railing against this decision and stated that 80% of Americans believed marijuana had medical value.  His point demonstrates the vacuousness of his argument.  He might support letting polling determine if a drug is safe and effective; but I trust the FDA and hard science to make these determinations.

I am sure that if we polled the public on the medical benefits of probiotics, gluten restriction, GMO foods,  organic foods, radiated foods, colonic detoxification, yoga, veganism and meditation that we might find that the public’s belief in these practices doesn’t have firm scientific support.   I do not argue that these dietary and lifestyle practices do not have health benefits or enhance life in other ways, only that they are either unproven or disproven.  There are still folks out there who believe that the measles vaccine causes autism, even though this theory has been thoroughly debunked. In my view, releasing a medicine to market requires firm scientific support.  Anecdotes and low quality ‘studies’ should be afforded the weight they deserve.

Should we open up the gates to all kinds of potions and elixirs that are unproven for the public?  We do!  They are called dietary supplements.  These agents are considered safe until they are proven to be dangerous.  Is this the standard we want for prescription drugs?

Sunday, September 11, 2016

Nursing Documentation vs Patient Care - Who's Leading?

I work with nurses every day.  Anyone who doesn’t realize how hard these professionals work, has never been in a hospital.  Their job descriptions have expanded along with their work load.  This is not your father’s hospital ward.  Hospitalized patients today are older and sicker than ever before.  It takes a seasoned nursing professional to manage the care of these complex patients.   Their work days are full simply managing the expected tasks of dispensing medications, coordinating diagnostic tests and assessing their patients.  There is no time scheduled for unexpected events, which are expected as sick people’s conditions may change at any moment.  In other words, if a nurse must attend immediately to a patient with chest pain, then his or her other more mundane tasks are delayed or shifted over to another busy nurse.

I believe that the most potent barrier that is separating nurses from their patients today is the ferocious documentation mandates that nurses are required to perform.  The hospital corridors are clogged with nurses hovering over computers entering all kinds of data, most of which will never be viewed by physicians.   These nurses are not techies who want to be palpating a keyboard.  They are compassionate caregivers who want to be in their patients’ rooms caring for them.

Tomorrow's Nurse?

If you suspect that I am exaggerating here, then go ask a nurse.

Moreover, the hospital’s electronic medical record system has become deeply layered and complex. Often I can’t find the specific data I need.  Just last week, a couple of senior nurses and I were scouring through the computer to find a patient’s result of stool testing for blood.  We simply couldn’t find it, and these nurses are pros.  At that point we were left with the following options:
  • Reorder the test
  • Make up the result
  • Quit the profession and become an Uber driver
  • Ask the patient what the result was
  • Hire a 12-year-old who could find the results in a few seconds.
While the computer record is packed with data concerning every aspect of the patient's medical experience, I have my own approach to find out what’s going on.  Pay close attention here.  Read the next sentence very slowly as I want readers to grasp the complex process I use each day as I approach the nurse.

“Hi.  What’s going on with my patient?”

Sunday, September 4, 2016