Results tagged “bedside medicine”
I am at the First Stanford Symposium on Bedside Medicine, and we have the world's leading experts on the diagnostic examination gathered here. It is a small group who still believe there is value in examining the patient, even in this era of imaging and technology.An anthropologist from Mars looking at our hospitals might conclude that the 'work' of medicine takes place in rooms far removed from the patient, typically in front of a computer screen. The actual patient and the person-hood of the patient is pushed to the margin of medical attention while the 'iPatient', the virtual patient rules.
Last night we talked about the ritual of the exam, and how important that ritual is. Rituals are about transformation, and the careful exam has all the elements of ritual, including a sacred space, a ceremonial garb (white coat and patient gown), a routine that is mysterious to the patient and includes disrobing and touch (which in any other context would be assault). Rituals are about transformation (think wedding, baptism etc) and this ritual when done well, is transformative, it establishes the physician-patient bond, it recognizes the body of the patient (the soma as opposed to the image of the body), and it is therapeutic, particularly in chronic disease, where the ritual repeated at every visit conveys to the patient that we are with them on the journey, we will not abandon them.
Everyone agreed to this aspect of the exam, the importance of ritual. Then why is it that we so rarely emphasize the importance of the ritual when trying to defend and preserve what is a threatened craft? I think it is because this ritual (like love, steadfastness, loyalty, courage) is not easily measured, and in a medical world that seems to be ruled by psychometricians, if it ain't measured it doesn't exist.
But hope springs eternal, and this little group is determined to bring about change.
(Photo: Flickr User mynameisharsha)
What always strikes me when I come back to being on the in-patient wards is the mountain of data that exists on each patient. It's a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that.
For example, if we admit to our service a patient who once had a transplant in our hospital, that guarantees records from many prior admissions--a veritable encyclopedia in the computer. Add to that everything generated in the hours that they were in the emergency room before making their way up to the ward (ER attending's note, blood tests, imaging studies, nurses' notes, consultants' notes) and you find that the real patient under the sheets is dwarfed by the labels and data that precede them. The task of sifting through that pile of information seems to get more challenging every year.
A few days ago my brother sent me a paper quoting the psychologist Herbert Simon who in 1969 lecture said:
"the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it."
Simon anticipated by 40 years the issue I've been wrestling with this week: is the information extant per patient, the sheer mass of it (measured not in stacks of papers, but in searchable gigabytes) at times detrimental to patient care? Data = mass = gravitational pull so that any of us opening a patient file enters a force field and find ourselves sucked in. For the interns' generation which has grown up on computers, the force is perhaps stronger or the nature of that kind of work is familiar.
Being a good doctor does involve carefully studying the old records. In the old days, one had to make an effort to go to the file room and get the dusty old charts, or if they were not there, track them to the cubbyhole where they awaited someone's signature. There was virtue in the effort simply because less conscientious physicians might not bother and they therefore might duplicate tests that needn't be done, or might miss the boat altogether in terms of what ailed the patient.
Nowadays, as I watch us all scour the digital records (no dust to inhale, no rubber bands that snap in your face) the task is so much easier. The new issue is that the information can detract and distract; we can wind up sitting too long in the chair staring at it. To paraphrase T.S. Eliot, knowledge can get lost in information, just as wisdom can get lost in knowledge.
On several occasions this week, I've felt that my time at our patients' bedsides, examining them (because only the exam can tell you if there is pain and if it's better than yesterday, and they seem more or less anxious today), learning who exactly they are, getting to understand what they want and most importantly listening to what they can tell us about their body, has helped make sense of confusing test results and contradictory stories piling up in the computer (and they pile up thanks to the cut-and-paste function which perpetuates misinformation).
So, in response to my brilliant student who is performing at the very highest level but who asked me this morning how he might get even better on the wards, I quoted Herbert Adam's words --poverty of attention-- which is going to be my new mantra, and I unveiled my Special Theory of Attentivity:
I suggested to him that Ac and Ap should at least be equal; preferably we should err to much more of Ap--time at the bedside. I suggested that he try to meet the patient in the flesh first before he shook hands with the patient's data; I suggested he work on getting as much as he can from listening to the patient, from sounding the body and only then turn to the computer. It's the opposite of how we now do things. I told him he might be humbled by what the records will show him he has missed, and he might be proud of what he has found that is not in the record or is wrong in the record.
I hope he'll find that his interaction with the patient will feel different, truly new because he will approach them without bias or labels.
Let's see what he reports. I have no doubt we will both learn something.
The word "empathy" is getting interesting play these days. At times it even sounds like a pejorative. President Obama used the word frequently while campaigning and since being in office. In the context of choosing a Supreme Court nominee, he said that ideally such a person should understand Americans' problems and have empathy for their fellow beings. But he's also talked about empathy (in Atlanta in Jan 09) in the context of its absence: "We have an empathy deficit when we're still sending our children down corridors of shame--schools in forgotten corners of America where the color of your skin still affects the content of your education . . . when there is Scooter Libby justice for some and Jena justice for others . . . when homeless veterans sleep on the streets . . ."
Most dictionaries will define empathy as "the intellectual identification with or the vicarious experiencing of the feelings, thoughts, or attitudes of another." Yet, for some, like Senator Orrin Hatch, President Obama's saying "empathy" when talking about judicial appointments is seen as a "code" for appointing a left leaning liberal. Instead of being seen as an admirable quality that describes someone with a visceral understanding of the human condition and especially of human suffering, it is seen as a bias.
To be fair, it could be that Republicans reflexively and correctly see the President's use of "empathy" as being empathy not for all people, but for some people, or even (in their view) the wrong people: for mothers instead of the unborn, for unions instead of big business, for the homeless and unemployed rather than for the well-off or even for the middle-class tax payer.
It did not help that Judge Sotomayor once said in a speech, "I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than the white male who hasn't lived that life." This would seem reasonable, but only if the issue at hand involved Latina women. What if the issue had to do with white men with un-rich experiences? One sees the slippery slope she is on.
As someone not in the legal field, it seems to me that if the law were absolutely cut and dry, and if the process of being a judge meant simply following algorithms, being impartial, ensuring that justice was done and procedure followed, then empathy would be irrelevant. But since judges always seem to be writing 'opinions' and disagreeing with each other, clearly, there is a human factor at work. In that case, broad empathy, a Shakespearean breadth of interest in all people, in the wise and the foolish, in the misanthrope and the saint, in politicians and the public who suffer them would surely be a good thing.
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I began my internship in 1980 at a Veterans Administration hospital in Johnson City Tennessee--the Mountain Home VA. To this day I don't think I have seen a more beautiful campus with quaint brick buildings, lush lawns, dogwood lining the main avenue, and white southern mansions in which the doctors lived.
But most beautiful and poignant was the cemetery, just to the right of the main entrance. Established in 1903 as a tribute to this corner of the "Volunteer" state that had contributed 30,000 volunteer soldiers to the Union, it was maintained beautifully. I would walk through that cemetery with reverence, the pages of history becoming more real when I read the names on headstones of men who had died in the civil war and every war since.
There was a plaque in the cemetery bearing these lines without attribution:
ON FAME'S ETERNAL CAMPING-GROUND
THEIR SILENT TENTS ARE SPREAD
AND GLORY GUARDS WITH SOLEMN ROUND
THE BIVOUAC OF THE DEAD.
I returned some years later as a specialist to work at that VA and I lived in one of the grand antebellum houses (or maybe they were post bellum--but they fit my idea of what antebellum looks like). I loved the old open wards, which, even though they were outmoded and needed to be replaced by semi-private rooms, seemed to recreate for the patients the intimacy, the camaraderie and the supportive environment of a barracks. I could often get from the patient in the next bed the low down on his neighbor's progress through the night.
My patients in those first days of my internship were largely World War II veterans, in their late fifties and sixties at the time. I recall the generosity of their spirit to us young physicians, and the stories they traded of service in North Africa, or the Pacific theater, or landing at Normandy. I wonder now how many of them are still with us--so much time has passed.
Tonight while writing this piece, I reached for my first book (which I have rarely gone back to because I immediately want to change things); it was the true story of AIDS arriving in that idyllic corner of east Tennessee.
Read MoreSincere thanks for all the comments, and the healthy debate. Democracy and civil discourse at work!
To respond to a few points from "A Concerned Physician" :
Of course, I am all for preventive medicine! Drugs for hypertension to prevent stroke, Vit A for blindness. . . who could be against that.? But if you put forth the hypothesis that preventive care will SAVE money (as the President proposes) . . . well, I'm sorry to tell you that the evidence (yes, evidence!) isn't there. The fact is if we do the right thing, cover everyone, get everybody to have regular check-ups, you will prolong life and uncover lots of treatable conditions that need investigaton, consultations and more treatment. I'm all for that. But it wont save money.
So please do read the article by Marmor et al titled, "The Obama Administartion's Options for Health Care Cost Control: Hope vs Reality" in the Annals of Internal Medicine (which I hope you will agree is ). The Congressinal Budget Office's reports projects little savings in this fashion.
As for IT and Electronic Medical Record (EMR), I'm no Luddite. I use it and can't remember what life was like before EMR. But again, if the thesis is that computerized records will SAVE money . . . well, I'm sorry but the evidence does not back that up. The Congressional Budget Office estimates that EMR will reduce national health care spending only "by an estimated $8 billion over the 2010-2019 period (or by less than one tenth of 1%)". In other words we are proposing to spend 20 plus billion to achieve these savings. [See the 08 Congressional Budget Office report, "Evidence on the Costs and Benefits of Health Information Technology "- -our taxes at work to produce these studies for us to read and hopefully save goverment from wasting tax money.]
The other problem which is more subjective and qualitative, is the effect the computer has on distancing physicians from the patient. I visited an ER with a friend recently, and nurses, docs, lab techs were interrogating the patient over their shoulder while making entries in the computer! It went on for hours. It was subjectively a poor experience overall for the patient, but if you were to study her record, I've no doubt it would shine and glisten like a jewel! The iPatient got wonderful care, while the real patient left disillusioned with medicine. I do think the EMR impedes medical education. (the link is to an article in PLoS) .
Finally, I don't think we we disagree on what we'd like for our patients, or on the benefits (from the time of Edward Jenner and small pox vaccine) of good science to find the best ways to treat and diagnose patients. But what I find annoying is the slavishness to that non-sequitir, "Evidence Based Medicine" that seems to shortcut critical thinking: I've seen too many patients railroaded into the "critical pathway" for pneumonia based on the best of evidence-based medicine, and by every metric the physicians did well and the hospital is pleased. The only problem was the patient didn't have pneumonia, but heart failure! A little more face time and less haste to plug people into EBM algorithms as if we are herding sheep down chutes would do much for patient satisfaction and improve medical care. We simply have no idea of the costs of those kinds of medical errors, of wrong diagnoses from people not spending time examining and interrogating the patient and re-examining and re-interrogating the patient.
So, to "Concerned Physician: I'm equally concerned. Alas, contolling costs, as our parents taught us, is best done by cutting costs, not by pie in the sky schemes that are postulated to save money. The remedy is painful but necessary.
p.s. I happily accept your label that my conclusions are drawn from ignorance. At least you and I will have the joy of not being alone! (-:
05/14/09 9:22 AM
If "Evidence Based Medicine" is like "Sex Based Intercourse" then "Comparative Effectiveness Medicine" is like . . .?
President Obama is in a bit of a bind, lets face it with his laudable goal to have health coverage for all uninsured Americans. The health care math is simple: we already spend a ton on health care and his goal will require spending more. His options are to generate new revenue, or the other option (the needed option, I would say) is to cut costs. But you saw what happened to Hilary years ago when she tried that. To quote from a great series of articles in the Annals of Internal Medicine, "A dollar spent on medical care is a dollar of income for someone." Cutting costs means cutting income for lots of different players and they won't be happy, and yet there seems to be no other way.
But President Obama thinks he can raise money largely through three methods that no one has proven can save money:
1) Investing in Information Technology: I don't see how that saves money but it does ensure that America's doctors will get better tans on their faces from long exposure to screen glow; the iPatient in the computer will get great care while the patient in the bed will wonder where the doctors are.
2) Preventive medicine: Studies actually suggest this usually costs more money, despite all the theories of how it should save money
3) And finally the President wants to invest in "Comparative Effectiveness" research so that we only pay for what works.
What helped create our present mess is a payment system that rewards procedures and expensive diagnostic testing, but does not reward primary care; it has necessarily resulted in a profusion of people and places who do things that are well reimbursed and a dearth of physicians doing primary care. We don't need comparative effectiveness research as much as we need a retooling of the payment system and some caps on spending. Let's pay for what works right now, and stop paying for what's not needed.
I worry that "Comparative Effectiveness" or "CE" is going to be the next medical buzz word, just like "Evidence Based Medicine" or "EBM" has been the buzz word for a decade. "Evidence Based Medicine" is a term which makes about as much sense as "Sex-based intercourse"--Were we practicing based on zodiac signs before EBM came along? (By the way, I borrowed "sex based intercourse" after hearing a prominent chair of medicine say it--I don't know if he coined it, but I thought it was brilliant). Soon we'll have a generation of physicians who are CE experts to bump out the EBM experts.
Lets take away the incentives to do to patient and instead create incentives to do for patients, to be with patients. We don't need to do comparative effectiveness trials to see if that works; we can just ask patients.
Abraham Verghese
