Thursday, March 15, 2018

There Is No Joy In Medicine








At least not nearly as much as there used to be.

I read a comment by a medical student recently who said that he found nothing in medical school - none  of the clinical rotations to be enjoyable at all.  As I looked back on it, at the interpersonal level there is a lot of subjectivity.  Although it was never stated personalities could make or break a rotation.  There was none of the anonymity of sitting is a large lecture hall and passing three or four tests.  As a medical  student, most of the teams I was on consisted of me, an intern, a resident and occasionally a more senior resident and one or more attending physicians.  Just as in real life, it was common to find people who really did not want to be on those teams.  They were fulfilling some sort of obligation.  As in real life, it was fairly common to be on a team where someone did not like you and if they were personality disordered could make your life a living hell.  But that was relatively rare.  As a medical student, the job was to keep your head down, not make any waves and absorb as much information as possible.

And some of those rotations were a dream.  A perfect combination of senior staff who knew they were there to teach, did a great job of it, and went the extra mile to be as cordial as possible to everyone in the process.  I have written about the last team I was on in medical school as an example.  The Renal Medicine team of of Milwaukee County Medical Center and Froedert Hospital in Milwaukee.  In those days there were three senior attendings who were also Professors in the medical school.  They ran an inpatient unit, outpatient clinic, and hypertension clinic. They also covered all of the inpatient consults. There was an associated group that took care of transplant and dialysis patients and all of the complications.  As a medical student my job was to do the initial patient interviews on the consults and present it to the team and round with the team on all of the inpatients.

It was an inspiring team to be apart of. One of the senior Internal Medicine residents was a guy who I had worked with before.  He was bright and had an incredible sense of humor. The most senior attending would give us all a hard time, but you could tell he was joking.  I never saw him lose his temper.  We were typically putting in 10-12 hour days with both patient care and didactics.  There was scheduled teaching time every day and plenty of teaching on the case presentations. Everyone was interested in the work and flexible. On my absolute last day of medical school the Internal Medicine resident told me they were swamped with admissions.  It was 6 PM and he knew I was graduating the next day.  He let me know that and then asked me if I could see 2 consults that needed to be staffed.  I did and felt good about it.  I lived about 1/2 mile away across the golf course sized county grounds and was ecstatic that night for completing medical school and that rotation.

Enjoyable rotations were not limited to medicine specialties.  I had plenty of contact with neurosurgeons in the same hospital.  The Neurosurgery residents had a grueling schedule starting as second year residents where they were basically on call every night.  They were in surgery in the morning and had to assess and treat acute emergencies in a very hectic emergency department.  The also ran a neurosurgery ICU.  On that service we rounded every morning and tried to get all of the work done on hospitalized patients by  11 AM.  The rest of the day was typically spent dealing with one emergency after another. The head of neurosurgery did not say much and appeared to be brusque, but he was an outstanding surgeon and teacher in the operating room.  We also had Radiology rounds every Saturday morning where he would review all of the imaging studies done on our patients in the previous week. That was a two month rotation for me and very enjoyable.

When I think of the common elements in those rotations that made them implicitly joyous - a few things stand out:

1.  They were intellectually rigorous:

There was no dispute that the teachers and professors knew the field inside and out and were interested in discussing it.  My only regret is that as a medical student - you really don't know enough to ask the best possible questions - at least I didn't.  My standard procedure was to study the problems that were being addressed in detail and in retrospect it might have been easier to ask a lot of questions.  Teaching occurred in detail and at length every day.  It was routine.

2.  They managed their own services:

These days practically all hospitalized patients are managed by hospitalists. Hospitalists will call in specialists as needed, but they basically assess the patient and leave a note in the chart.  People will say this is more efficient and have that same argument about primary care physicians not seeing their own patients in the hospital - but a lot is lost in the process.  Teaching is an obvious casualty. Are you going to learn more about a patient who is on your service 24/7 or one who you drop by and leave a note for the hospitalist team?  I have seen medical students following consultants around and they often look bewildered.  As a team, there is a sense of belonging and typically a place to hang your hat and discuss the work every day.

3.  There was no outside interference by the business world:  

The hospital landscape has become bizarre relative to the hospitals I trained in. Instead of morning rounds - you might see a team of physicians in a "huddle" in the morning.  That huddle may contain non-medical staff and administrators who have no role in patient care. There are really there to manage physicians. Some might tell physicians when to discharge patients.  Others are just there to report what physicians are doing to senior management.  Let me clarify that these are not multidisciplinary treatment teams. I had 20 years of those teams meetings that were clinically focused and then one day there was a case manager in that group and she was reporting what I was doing to a hostile medical director who threatened to override my decisions. At a team level there was an equally malignant administrator trying to undermine the relationship between medical and nursing staff.  It is clear from my medical school experience that none of the managers were necessary and they made the clinical situation much worse. Add utilization review and prior authorization done by companies with an obvious conflict of interest and the hospital landscape suddenly becomes a complete nightmare.  I found myself in the position of needing to go though 2 hours of prior authorization time in order to discharge patients on the same medications that they came in on. In other words the medications were already authorized but I had to do it again.

4: Physicians weren't treated like criminals:  

Physicians tend to not be very good with politics and have a short memory but I don't.  In the 1990s, a billing and coding system was introduced that was supposed to capture physician work and provide commensurate reimbursement.  Unfortunately the inventors of this system did not realize that it was totally subjective and far too detailed. In the only study ever done on the validity of the system, the chance the any two coders could agree on the same billing code was a coin toss. In the meantime, at some point during that decade my hospital colleagues and I were cloistered in a lecture hall and told that any mistakes on our documents were a crime and if a billing statement went out based on that crime - we could be prosecuted under federal racketeering charges. In the meantime, the FBI was raiding doctors offices and trying to make documentation errors into a federal crime.  Eventually the federal government must have seen this was a bit heavy handed and they turned enforcement over to compliance monitors in organizations.  I was awarded the "best documentation" one year by a compliance officer and the next year it was the worst. Over that year, I had made no changes to my documentation. Today there is a mountain of worthless documentation that takes each physician about 3-4 extra hours per day to produce that is the direct result of this initiative. If I was back on my neurosurgery rotation - the document would have been 3-4 handwritten lines.

5: Everybody was an expert - not pretending to be one:

Fake medical news is common across all social media.  Journalists commonly print the story that they want rather than reality.  A common story on this blog is is how physicians were bought off by (often trivial) gifts and this led to inappropriate prescribing and massive drug company profits. It was a good story while it lasted and some media is still trying to push it but when gifts to physicians were eliminated, the USA still has by far the most expensive pharmaceuticals in the world.  There are even more provocative headlines out there that don't pass the smell test.  It is in the best interest of click-bait journalists and business administrators to make it seem like knowledge in medicine is relative and anyone can possess it.

6:  Clinical care was cohesive and not fragmented: 

Business innovations in medicine leave a lot to be desired.  When the field is structured around the ideas of business managers and some of these problematic ideas are published as commentaries in prestigious medical journals - adequate care becomes an increasingly remote possibility.  On the services I mentioned patients were triaged to receive the state of the art care of the day.  They did not end up seeing a series of physicians or providers who had no clue about how to address the problem and hoping to see the appropriate specialist.  In fact one of the most embarrassing developments of managed care was the idea that they were going to put specialists out of business or install a gatekeeper to see who gets referred to a specialist.  There are ample examples on this blog of the importance of seeing the appropriate specialist without having to deal with any administrator erected obstruction.  The main fracture in medicine at this point has been the destruction of the psychiatric infrastructure and the incarceration of the mentally ill.

Just a few obvious reasons why my most joyous experience in medicine happened in medical school over 30 years ago.  I think it could all be distilled down to the basic truths of autonomy, professionalism, a singular patient focus, an intellectual approach to the field, and doing the right thing. That is when you have hard working physicians who enjoy the work and are not burned out.  Medicine is currently creaking under the weight of bad ideas from politicians and bureaucrats and all of the associated rationalizations.

It is no wonder that I often find myself thinking about my old renal medicine and neurosurgery teams and whether future physicians will ever be able to capture that joy again.

It is no wonder that when Grace Slick sings with conviction over my Bluetooth player that I am focused on those first 4 lines.......



George Dawson, MD, DFAPA




Graphics Credit:

Photo licensed directly from Gijsbert Hanekroot Fotografie. Title below:

Jefferson Airplane Perfornm Live At Kralingen Festival
ROTTERDAM, NETHERLANDS - JUNE 26: Grace Slick and Jorma Kaukonen from Jefferson Airplane perform live at Kralingen Festival in Rotterdam, Holland on June 26 1970 (Photo by Gijsbert Hanekroot/Redferns)


Lyrics:

From the song Somebody To Love performed by Jefferson Airplane.  Words and music by Darby Slick.


Supplementary:

Interested in Grace Slick photos from around the time of the release of this song. Contact me if interested.

5 comments:

  1. So what are we going to do WHEN Health Care becomes Universal?

    You think the current medical students are lost and bewildered, they're going to wind up hating their lives because they won't be able to retire or quit.

    Frankly, I look forward to watching States like California and New York become third world countries when the state of health care collapses!

    Yeah, I know people will think that's cruel and harsh, but when politicians can completely run Healthcare, we are truly and utterly doomed!

    Joel H

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    1. I think the politicians and their business proxies currently run health care and are directly responsible for the poor quality. Health care has essentially collapsed with the exception of a few islands. I hope to post a very common example over the weekend of what can happen if you are an old guy with the fairly common condition of bladder outlet obstruction secondary to BPH. The way that case was managed is a stunning illustration of how health care in the USA looks good on paper but nobody is stepping up to make the right decisions.

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    2. Joel: Having worked for the VA for a time, I have no illusions about government-run health care. But since having universal health care is the model for the entire developed world except here, I think you are making just a bit of an overstatement. Has health care collapsed in Germany and Scandinavia? Don't think so. Also, private insurance companies and their lackies are in many cases unquestionably even worse than the government. Government especially does not do a good job when it is being run by people who are out to prove that government does not work.

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    3. With all due respect gentlemen, while I have no respect nor appreciation for the private insurance industry, I have even less for government run systems. Frankly, the physicians I have had interactions with who seem to speak at least neutrally if not positively for systems like the VA, well, haven't met many patients who even speak neutrally about the VA.

      It brings me back to what Ayn Rand wrote about her physician character in Atlas Shrugged:

      “I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”

      That last sentence there is what reinforces the point, who are the physicians who don't care about being manipulated and controlled? Yeah, being a dissenter or whistleblower doesn't result with much if any positive endpoints, but, I value the Hippocratic Oath. When the chipping away is insidious and subtle, well, how's that pot on the stove heatin' up, folks?! Shame the frogs and lobsters don't have the ability to speak out!

      Another quote, from a great song by Bruce Hornsby: "That's just the way it is, but, don't ya believe them!" Enjoyin' that Personality Disordered Society much these days?...

      Joel H

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  2. "Also, private insurance companies and their lackies are in many cases unquestionably even worse than the government."

    There is absolutely no doubt about that.

    The best example I can think of is the PRO or PRSO programs in each state from the 80s and 90s. There reviewed all Medicare admissions for utilization and quality concerns. The markers were actual medical quality markers not patient satisfaction surveys. I was a PRO reviewer in WI and MN for about 15 years. All of the reviewers were screened for financial conflicts of interest. You were NEVER allowed to review any hospital or clinics that you were affiliated with as opposed to the hired guns that work for MCOs and PBMs. The best part about that PRO experience was that after you remove that conflict of interest - "overutilization" vanishes. The program was phased out because it did not find enough "overutilization" to justify the cost.

    Like everything in American - special interest politics carries the day and that fact was buried so that managed care and all of its problems could be justified. It is a complete waste of time and money.

    A related issue is the idea that "the government" is going to run things. I have a post here comparing the USA to the next most expensive health care system in the world - Switzerland. On a per capita basis the USA system is about $1 trillion more expensive and access and quality are lower - much lower for psychiatry and mental health.

    The Swiss system is NOT single payer. European governments and Japan have a number of ways that the government uses to keep costs down. Stepping in to totally run the health care system the way that single payer is described - rarely happens. The clearest example is setting more reasonable pharmaceutical costs.

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