Here's an interesting study this week from the Journal of the American Medical Association that looks at how often patients underwent a stress test prior to getting angioplasty. In turns out that less than 50% of the time! And so why is this a big deal?
Angioplasty is where a small balloon is used to open up a coronary artery to relieve a blockage, followed sometimes by the placement of a stent to keep the vessel open. It is much less riskier and invasive than open heart surgery and is well known to save lives in people having heart attacks and in those with unstable coronary disease. However, we know that in people with stable coronary disease angioplasty has no more benefit over medical therapy (nitro, blood pressure, and cholesterol meds). The difference between stable and unstable CAD is basically how and when you get symptoms of reduced blood flow to the heart (chest pain, shortness of breath, and so on). In stable CAD you only get these symptoms when your heart is stressed, say when you are climbing the bleachers at the football game, arguing with your spouse, or watching our fine President make an ass of himself on television. So according to our best medical evidence, if you fall into that category you're most likely to be best off with just taking your medicines following your doctor's good advice to exercise and eat your veggies, and staying the hell away from the cardiologist.
Naturally, it is never easy in medicine to separate people nicely into one group or the other. Several professional societies such as the American Heart Association have published guidelines stating that for any non-emergent (elective) angioplasty a patient should have a stress test first to demonstrate myocardial ischemia, that is, insufficient blood flow to your heart muscle. There are lots of types of stress tests, but the principles are the same: make the heart work harder (running on a treadmill) and measure function of the muscle (EKG, echocardiography, nuclear perfusion scans). The tests help sort out if there is ischemia (not all patients with poor blood flow will have symptoms, typically women) and if there is chest pain if it is due to an angry, blood-starved heart or not.
It seems intuitive that just ballooning open vessels with plaques is a good idea. Strangely, we know the probability of having a heart attack is not easy to predict from the degree of vessel narrowing alone. What determines your heart attack risk are based on several factors, and many people with narrowed coronaries or stable CAD never have a heart attack. So its seems it is not simply a structural problem. Hence, the need for the stress test, which allows the doctors to identify the functional nature of the vessel. Incidentally there is trendy new use of CT scans (CT angiography) that takes thin slice, high-resolution images of just your coronaries and is able to actually image individual plaques. The 3-D reconstructions are pretty amazing to say the least. But, the utility of the scans are controversial because they don't tell you which plaques are likely to be trouble makers, which is what we really want to know. Nevertheless, lots of doctors are totally into the scans and convince their patients they need to have them, and so in some places every middle aged man with a history of chest discomfort is getting this expensive trip to the CT scanner. This is a great example of how our medical system readily embraces new technology that seems promising before evaluating the evidence behind its efficacy.
Okay, back to angioplasty. So why the hell are so many people - more than 50% - getting ballooned and stented before verifying that they have a functional vessel problem? That's the question this study raises. A generous explanation is that doctors either intentionally or unintentionally ignore the guideline recommendations, relying instead on personal experience and local practice standards. Call me a pinko Francophilic Obama-loving Terrorist, but my own opinion is that this is just another example of how the fee-for-service system incentivizes doctors and hospitals to provide care that may not actually benefit patient. But to be fair there are other non-financial aspects of medicine that muddy the waters: our professional ethics urge us to provide the best care regardless of cost and over-treatment serves as a bet-hedging maneuver in the paranoia of malpractice claims.
15 October 2008
13 October 2008
A Few Thoughts on the ICU
I'm finishing my rotation in the ICU. It is an immensely interesting place to work, but frustrating as well. To my surprise, I do not find the degree of suffering and high mortality depressing. I am sort of happy - relieved - when patients expire (the medical term for die) because most of what we do in the ICU is prolong death, and by extension, pain and suffering.
The moral conundrum encountered daily in the ICU is that we have advanced technology to keep people alive even when a disease process is inevitably leading to death and is medically irremediable. Family members, staff, physicians, and even patients themselves who are still lucid, often conflate the benefits of life support therapy with medical progress. The fact that a ventilator and blood pressure medicines keep dad from dying is interpreted as possibility that things may turn around. In these stressful times people listen to what they want to hear. They cling desperately and hopefully, to small, but medically trivial, "positive" changes in body function - such as blood pressure - from one day to the next.
Family members often want to know "the numbers" - the results from lab tests, vitals signs, and so on. I am learning, however, it is often counterproductive to discuss this data in much detail. A 1-point increase in hematocrit (red blood cell concentration) will be taken as a sign that dad's still hanging on, when in the context of all the other data, it may very well be meaningless. Sure, you tell the family that, "well, the overall trend is such and such, and that number does not necessarily mean so and so" but like I said, people hear what they want.
In other areas of medicine I am very much a proponent of transparent communication. Tell the patient the data, give him a sense of what they mean (to my best medical opinion), elicit questions and then let him decide what to do.
So why is that a problem in the ICU? Most lay people with a loved one dying in the ICU grossly underestimate the severity of the disease process at hand, while at the same time they overestimate the ability of modern medicine to reverse that process. Also, many people dying in the ICU have several organ systems failing, and putting the whole picture together can be very complicated, even for someone who's medically trained. Most people can easily understand the prognosis of a back sprain or even a heart attack, but that of a critically ill patient is altogether different.
For me the most frustrating thing about the ICU is that we are often too focused on preserving life at all costs and loose sight of what the patient might want, what is the likely outcome for the patient even if they do survive, and their pain as we keep them alive. There is a lot of guilt that drives decision making in the ICU, both among family members and doctors. We forget that it is the disease that kills a patient, not the withdrawing of life support. Even people who feel it is a Christian duty to preserve the sanctity of life at all costs seem to forget that it was God who inflicted the disease on this patient in the first place, and that all our life preserving interventions just obstruct the natural process he has willed into existence.
The ICU, as many people may guess, is incredibly expensive. Nowhere in medicine have I seen such exorbitant, egregious use of health care resources. It sounds heartless to insinuate that every patient comes in with a price on their life. But honestly, who ends up paying for a 2-week stay in the ICU with several very expensive medications, CT scans, MRI scans, and so on? Some of the debt is carried by the family, others by the insurance company or hospital, which is to say, the rest of us in the form of higher premiums. One patient I admitted for fulminant alcoholic liver failure recently died after 3 weeks in the ICU. At $3500/day that's over $70,000 just for the room. I think this is a fair price to pay for someone who has a reasonable chance to survive the disease (this guy's pre-hospital mortality was 60% within 3 months) and a reasonable chance of returning to be a functional member of society.
I know that's not a warm-and-furry approach to life; but then again I didn't invent alcoholic liver disease; that's just reality of life and death. Of course most situations are gray and drawing the line between a good and poor prognosis is notoriously difficult and inaccurate. However, there is no doubt that a more open cultural attitude about death and socialized medical system in which health care budgets were fixed, would allow us to more clearly mark that line without guilt. And that I think would be better for all of us, including dad.
The moral conundrum encountered daily in the ICU is that we have advanced technology to keep people alive even when a disease process is inevitably leading to death and is medically irremediable. Family members, staff, physicians, and even patients themselves who are still lucid, often conflate the benefits of life support therapy with medical progress. The fact that a ventilator and blood pressure medicines keep dad from dying is interpreted as possibility that things may turn around. In these stressful times people listen to what they want to hear. They cling desperately and hopefully, to small, but medically trivial, "positive" changes in body function - such as blood pressure - from one day to the next.
Family members often want to know "the numbers" - the results from lab tests, vitals signs, and so on. I am learning, however, it is often counterproductive to discuss this data in much detail. A 1-point increase in hematocrit (red blood cell concentration) will be taken as a sign that dad's still hanging on, when in the context of all the other data, it may very well be meaningless. Sure, you tell the family that, "well, the overall trend is such and such, and that number does not necessarily mean so and so" but like I said, people hear what they want.
In other areas of medicine I am very much a proponent of transparent communication. Tell the patient the data, give him a sense of what they mean (to my best medical opinion), elicit questions and then let him decide what to do.
So why is that a problem in the ICU? Most lay people with a loved one dying in the ICU grossly underestimate the severity of the disease process at hand, while at the same time they overestimate the ability of modern medicine to reverse that process. Also, many people dying in the ICU have several organ systems failing, and putting the whole picture together can be very complicated, even for someone who's medically trained. Most people can easily understand the prognosis of a back sprain or even a heart attack, but that of a critically ill patient is altogether different.
For me the most frustrating thing about the ICU is that we are often too focused on preserving life at all costs and loose sight of what the patient might want, what is the likely outcome for the patient even if they do survive, and their pain as we keep them alive. There is a lot of guilt that drives decision making in the ICU, both among family members and doctors. We forget that it is the disease that kills a patient, not the withdrawing of life support. Even people who feel it is a Christian duty to preserve the sanctity of life at all costs seem to forget that it was God who inflicted the disease on this patient in the first place, and that all our life preserving interventions just obstruct the natural process he has willed into existence.
The ICU, as many people may guess, is incredibly expensive. Nowhere in medicine have I seen such exorbitant, egregious use of health care resources. It sounds heartless to insinuate that every patient comes in with a price on their life. But honestly, who ends up paying for a 2-week stay in the ICU with several very expensive medications, CT scans, MRI scans, and so on? Some of the debt is carried by the family, others by the insurance company or hospital, which is to say, the rest of us in the form of higher premiums. One patient I admitted for fulminant alcoholic liver failure recently died after 3 weeks in the ICU. At $3500/day that's over $70,000 just for the room. I think this is a fair price to pay for someone who has a reasonable chance to survive the disease (this guy's pre-hospital mortality was 60% within 3 months) and a reasonable chance of returning to be a functional member of society.
I know that's not a warm-and-furry approach to life; but then again I didn't invent alcoholic liver disease; that's just reality of life and death. Of course most situations are gray and drawing the line between a good and poor prognosis is notoriously difficult and inaccurate. However, there is no doubt that a more open cultural attitude about death and socialized medical system in which health care budgets were fixed, would allow us to more clearly mark that line without guilt. And that I think would be better for all of us, including dad.
05 October 2008
Thoughts on Medical School Burnout
Lost month in the Annals of Internal Medicine a study on medical student burnout and suicidal thinking, and then a commentary in Slate.com. I hear a lot these days in the press, blogs, at work among colleagues, about how stressful the medical profession has become.
Having had a previous career prior to medicine, I can say for myself at least that there is more stress in medicine than the tech industry, but it is not because of long hours as many people think. I think it is primarily because of the type of stress - the responsibility of managing people with complex medical conditions, the pressure of high-patient turnover, and the legal implications of medical decision-making. These all make medicine more emotionally charged than in other professions. On top of that is the type of work schedule. Many people in other professions work 80 hour weeks. But only in medicine is it typical to work extremely long periods 30 or 48 hours, or be on call when you have to be available around the clock. That's difficult because it messes up routine, your sleep, it become impossible to plan anything. An 80 hour workweek is heavy, but it makes a big difference if those hours are predictable and separated with periods of recovery.
The stress of being a medical student is also unique. Commonly voiced complaints are the ridiculous cost of medical education ($100-150K) and the endless training (min of 7 years after college). These feed into each other since indebtedness leads people to seek more training in higher paid specialties.
For me "burnout" in medical school has not been about working long hours or dealing with unpleasant patients. It is about the pressure of getting good evaluations in a environment where expectations of my roles and responsibilities are poorly defined, combined with a sense of ennui because I am not given any responsibility for patient care.
There are high expectations of you to know a lot that you don't really know, often times before you've ever been trained. Expectations are constantly shifting and are totally dependent on the team you are working with that week. And just as you get the hang of something, you switch clerkships and possibly hospitals sites as well. This is like starting a new job every 4-6 weeks; new nurses and staff you don't know, a new space where you don't know where anything is, new residents and attendings - your bosses essentially - with their own way of doing things. And all along you get evaluated by every resident and attending you work with, even if it is for a few days.
But beyond all that, the worst part about the clerkship years for me was that I was totally useless. As a student you can't write medical orders, so your role is limited to glorified shadowing - following your team around and observing. At OHSU, a large academic medical institution where there are many residents and other students, there is considerable competition for patients. Residents and interns have priority in managing patients and doing procedures; the student is last to know new test results, handle a scope, or peak into a wound. Yes, you do your own exams and write your own notes, but these are meaningless to the patient's care because the resident and attending also do this as well (nothing done by a student can be billed to the patient). I was told by one attending that I needed to act as if the patients were my patients, that is, take ownership of them. This was really frustrating, especially for someone like myself with a previous career with managerial responsibility, because the system is not designed to allow a student to do that in any meaningful sense.
Most student's motivation during clerkship is to get a good grade, and that's done by convincing your team that your a good student. But how do you do that? Attendings and residents rarely, if ever, observe your exams or interviews. Often times they don't really read your note in any detail. So your evaluations hinge largely on your presentations, those few precious minutes during the day when all eyes and ears are turned to you. Presenting a patient is a vital skill in medicine and doing it well is an art; this kind of emphasis in medical school clerkship is corrupting.
And here why: If I had an hour to see and prepare a progress note for my attending, I would best be served by spending as little time as possible seeing the patient - get in, get out - and the rest looking up new literature or reading up on the disease. Indeed, knowing your literature is crucial to being a competent doctor. But shouldn't bedside care also be? Sadly, bedside care is actually one of the ways in which a student can "add value" to the care delivered to a patient. Our system does not reward the student who takes bedside care seriously. Patients never evaluate students; and attendings only evaluate what they see: the fruit of diligent study appearant in an impressive assessment and plan.
Sure, I've learned a lot the last 18 months during my clerkships, but I am eager to move on and actually do work, to have some responsibility and feel accountable.
Having had a previous career prior to medicine, I can say for myself at least that there is more stress in medicine than the tech industry, but it is not because of long hours as many people think. I think it is primarily because of the type of stress - the responsibility of managing people with complex medical conditions, the pressure of high-patient turnover, and the legal implications of medical decision-making. These all make medicine more emotionally charged than in other professions. On top of that is the type of work schedule. Many people in other professions work 80 hour weeks. But only in medicine is it typical to work extremely long periods 30 or 48 hours, or be on call when you have to be available around the clock. That's difficult because it messes up routine, your sleep, it become impossible to plan anything. An 80 hour workweek is heavy, but it makes a big difference if those hours are predictable and separated with periods of recovery.
The stress of being a medical student is also unique. Commonly voiced complaints are the ridiculous cost of medical education ($100-150K) and the endless training (min of 7 years after college). These feed into each other since indebtedness leads people to seek more training in higher paid specialties.
For me "burnout" in medical school has not been about working long hours or dealing with unpleasant patients. It is about the pressure of getting good evaluations in a environment where expectations of my roles and responsibilities are poorly defined, combined with a sense of ennui because I am not given any responsibility for patient care.
There are high expectations of you to know a lot that you don't really know, often times before you've ever been trained. Expectations are constantly shifting and are totally dependent on the team you are working with that week. And just as you get the hang of something, you switch clerkships and possibly hospitals sites as well. This is like starting a new job every 4-6 weeks; new nurses and staff you don't know, a new space where you don't know where anything is, new residents and attendings - your bosses essentially - with their own way of doing things. And all along you get evaluated by every resident and attending you work with, even if it is for a few days.
But beyond all that, the worst part about the clerkship years for me was that I was totally useless. As a student you can't write medical orders, so your role is limited to glorified shadowing - following your team around and observing. At OHSU, a large academic medical institution where there are many residents and other students, there is considerable competition for patients. Residents and interns have priority in managing patients and doing procedures; the student is last to know new test results, handle a scope, or peak into a wound. Yes, you do your own exams and write your own notes, but these are meaningless to the patient's care because the resident and attending also do this as well (nothing done by a student can be billed to the patient). I was told by one attending that I needed to act as if the patients were my patients, that is, take ownership of them. This was really frustrating, especially for someone like myself with a previous career with managerial responsibility, because the system is not designed to allow a student to do that in any meaningful sense.
Most student's motivation during clerkship is to get a good grade, and that's done by convincing your team that your a good student. But how do you do that? Attendings and residents rarely, if ever, observe your exams or interviews. Often times they don't really read your note in any detail. So your evaluations hinge largely on your presentations, those few precious minutes during the day when all eyes and ears are turned to you. Presenting a patient is a vital skill in medicine and doing it well is an art; this kind of emphasis in medical school clerkship is corrupting.
And here why: If I had an hour to see and prepare a progress note for my attending, I would best be served by spending as little time as possible seeing the patient - get in, get out - and the rest looking up new literature or reading up on the disease. Indeed, knowing your literature is crucial to being a competent doctor. But shouldn't bedside care also be? Sadly, bedside care is actually one of the ways in which a student can "add value" to the care delivered to a patient. Our system does not reward the student who takes bedside care seriously. Patients never evaluate students; and attendings only evaluate what they see: the fruit of diligent study appearant in an impressive assessment and plan.
Sure, I've learned a lot the last 18 months during my clerkships, but I am eager to move on and actually do work, to have some responsibility and feel accountable.
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