Monday, December 25, 2006

Hospitalized on Christmas

This morning as I rounded on my patients in the hospital, I wished each of them a Merry Christmas. It felt good to say but at the same time slightly odd, not because I worried that somebody wasn’t Christian, but because spending your Christmas sick in the hospital probably isn’t anybody’s idea of a merry Christmas. It’s kind of like when you go to the doctor and he asks you, “how are you?” and you say “fine, thanks,” to be polite, but you both know that if you really were fine you wouldn’t be there in the first place. The exchange somehow only serves to highlight that something is wrong. And so wishing Merry Christmas to my patients, as cheerfully as I tried to do so, in part only seemed to emphasize their misfortune. For no matter how caring your nurses, how thoughtful your physicians, how friendly your roommate, how beautifully decorated the hospital, how frequent your visitors, the ugly truth remains that the hospital ward is a horrible place to spend Christmas.

It’s only the last couple of years when residency has prevented me from returning home to Alaska over Christmas that I’ve realized the importance of spending Christmas at home. My parents have been coming here to celebrate with my brothers and me, but as nice as it’s been to see them, Christmas in Washington just isn’t the same. What’s missing? The boxful after boxful of Christmas decorations that my mom starts putting up after Thanksgiving; the making and decorating of gingerbread cookies with Dad; the mustard-encrusted Swedish Christmas ham that provides daily lunchtime ham and cheese sandwiches; the luxury of being on vacation; the Christmas tree with its entourage of multi-shaped and multi-colored Christmas presents; the straw Swedish Christmas goat with its red necktie; the cozy darkness that sets in shortly after noon and the Christmas lights that softly brighten it; the dozen or so different kinds of Christmas cookies that Mom bakes; the nightly living room concerts with us brothers alternately singing and playing the piano; the glowing white snow coating the entire outdoor landscape; Swedish Christmas dinner on Christmas Eve with broccoli soup, spare ribs, meatballs, potatoes, glogg, whipped rice pudding dessert; American Christmas dinner on Christmas Day with the entire extended family. In short, what’s missing in Christmas in Washington for me is everything that makes Christmas special.

Patients realize this as well. They do their darnedest to stay out of the hospital over the holidays, minimizing symptoms, ignoring pains, waiting out dizzy spells, in vain attempting anything possible to convince their fragile bodies that staying home will be ok. One of the questions we normally ask when admitting patients is what changed in their condition that day that made them seek out medical attention. (Admittedly, sometimes we are curious why, if the pain has been going on for six months, the patient decided to come in just on our particular shift.) During the holidays, though, we instead find ourselves asking, “Why on earth did you wait so long to come in?” The invariable answer: I was hoping I could make it through the holidays. It’s hard to be mad at a patient like that. I mean, you’d think people would realize when they can’t move one side of their body that the problem bears some urgency, but just wanting to spend Christmas at home is a wish that's much too understandable. Those patients, despite their best efforts, will hear Merry Christmas from someone like me. Others, though no more determined, are more lucky. The medicine service at my primary hospital averages roughly sixteen or so admits over every twenty-four hour period during the winter. Over the past three days, we had seventeen admissions total. Pity the resident who gets assigned call on the day after Christmas.

As the hospitalized patients and I have discovered, though, there are worse things still than spending Christmas in the hospital. On the bright side, and despite its reputation for being a cold and foreboding place, the hospital actually turns out to be quite conducive for meaningful human encounters, conversations, and interactions. Telling someone that you love them is easier in the hospital. People are always around, so nobody has to be completely alone. Additionally, there is a deeper sense of camaraderie in the hospital during the holidays, as healthcare workers from the top of the command chain to the bottom feel increased solidarity and commitment to our profession.

For these reasons, my mood was bright this morning as I showed up for work, and I was genuine in wishing each of my patients a Merry Christmas, and in hoping that I wasn’t just rubbing in that they were more or less missing Christmas this year. They smiled and wished me a Merry Christmas in return, the more clever ones maybe feeling reciprocal misgivings in figuring that rounding on sick patients in the hospital wasn’t exactly my preferred way of spending Christmas either. But despite our perhaps mutual concerns, and despite our less than ideal circumstances, on both sides I think we took satisfaction in the greeting. Because when it comes down to it, no matter what your religion, and no matter what your disposition, it’s hard to take a well-wishing negatively, especially when that wish is for a Merry Christmas on Christmas Day.

Wednesday, December 20, 2006

Staying the course

One of the best attendings that I’ve ever had was an ICU attending whom I worked with as a fourth year medical student. Born, raised, and educated in India, he had completed his residency and fellowship in the U.S. and stayed on to become a bright and shining young medicine professor. Although his bedside manner was somewhat hampered by an inability to mince words, his patients were always keenly aware that they were receiving outstanding medical care. Each morning on rounds as he listened to patient presentations, he would focus carefully on every word, furrowing his brow at any irregularities or surprises. He would jot down notes, pouring over the data on his flip cards, and when the presentation had finished and the plan had been fully presented, he would reach into his magical hat of medical tricks and pull out an additional suggestion or two. No matter how long the patient had been in the ICU, with the same illness and the same basic treatment plan, he always had something new to offer, be it an antibiotic change, a new bowel regimen for constipation, a new physical therapy activity, or any other small change that might improve patient care or comfort. Staying the course was not part of his vocabulary. Although he didn’t explicitly state it, my attending seemed to feel that if there was not some new thing he could do for each patient each day, he would be better off just staying home.

Of course, now the specific language has been ruined for us by the war in Iraq, but the concept of staying the course was never a very good one to begin with. Whether in medicine, warfare, or just everyday life, staying the course implies a lack of imagination. It means that you can’t think of anything else to do that might improve your situation; that you are plain out of ideas, run completely dry. There are certainly times when a therapeutic plan or maneuver takes more than one day to implement and/or see through, but staying the course suggests satisfaction with the current progress and hesitancy to attempt anything else. As I learned in my ICU rotation, however, there’s almost always something more you can do.

Self-help isn’t really my thing, but I wonder what would happen if we applied our hospital techniques of patient evaluation to ourselves. What if we woke up each morning and asked ourselves if we had any concerns since the day before; if we examined ourselves, reviewed our own charts, considered in detail each of our own active and chronic issues and the best daily plan for each. It would certainly be overkill, and should we find ourselves behaving in such a way, ordering psychiatric evaluation of ourselves would definitely be warranted. Yet, if we were able to look past the eccentricity of holding self conversations and thinking about ourselves in the third person, imagine the power of addressing our problems in such a systematic and thoughtful way. Nearly anything could be conquered, any goal achieved. And if we believed that a new day was worthy of a new approach, idea, or endeavor, that in general it would be ok to maintain the overall plan but that the details would demand something fresh to be discovered or pursued, then the power to achieve and to build success would only be greater. A higher quality of life could perhaps be achieved. And the previous day would have to be truly amazing before one would ever say on the following one that the plan was simply to stay the course.

Wednesday, December 13, 2006

Publication bias

One of the field of medicine’s most attractive qualities is that it is inhabited by people of skeptical minds, and to convince anyone of anything requires quite a substantial feat of proof. I suppose the underlying reason for this is that do no harm remains one of our central tenets, and when patients’ lives are at stake, we want to be absolutely sure we know what we’re doing.

In contrast, I’m continuously amazed at how low the threshold for acceptable evidence seems to be in the public sphere. The guilt by association smear is a particularly common and egregious example of this, as it insinuates without offering any evidence at all. (e.g. Nancy Pelosi sounds a lot like Michael Moore these days, talking about limiting the sale of handguns.) More dangerous is when evidence is used to draw conclusions that it doesn’t actually support. I remember watching a debate about gay and lesbian adoption rights on the Oprah Winfrey show a few years ago and getting irritated as one of the speakers kept citing evidence that children raised without fathers do less well than other children, in support of his claim that lesbian couples make inferior parents. Nobody on the show pointed out the ridiculousness of this logic, but in a medical conference he’d have been a laughing stock. Let me get this right – instead of studying the children of lesbian couples, you want to make assumptions about them using the children from broken homes as a proxy? I have a better idea, how about I prescribe you a medication for attention deficit disorder that has been proven safe in tortoises! Never mind that by his logic gay male parents would have made the best child-rearers, as they'd have provided the steady influence of not one but two fathers. I’d have found this man much less objectionable had he simply stated that he was opposed to lesbian parents because he was opposed to lesbianism.

One of the ways that we can stay honest, in medicine and in life, is by identifying bias in the information that we receive. The point isn’t necessarily to eliminate the bias, but simply to recognize it so that we can factor it in when we form opinions. Conservatives, for example, would like us to correct for what they see as a liberal media bias. Claiming that the news is biased, however, is a dangerous game to play; if the news seems biased, that is, if reality seems biased, it implies that the bias actually lies in the person perceiving it.

A kind of bias that I find particularly fascinating and that is commonly described in medicine is publication bias. Publication bias results from considering only information that has been published and neglecting other information. If you think about it, publication bias in one form or another influences everything that we learn and know, since we are unable to access information that hasn’t been published or broadcast in some way. By filtering out information that is not worth being heard, publication bias serves as a useful form of quality control, but it does mean that we must rely on others to supply us with information that’s relevant, important, and entertaining. On the micro level, in conversation between people, publication bias becomes speech bias. When talking with someone, you only hear the thoughts that they decide are worth or safe speaking. Since the dullest, dumbest, and riskiest thoughts are filtered out, speech bias makes people seem smarter than they actually are, and probably leads us to doubt our own capability and worth. Maybe those really arrogant people out there in the world would seem less intimidating if we could somehow eliminate this bias. There are definitely certain minds where I would love to implant a thought recorder and register the thinking as is. Of course, unfiltered speech can also be hazardous – I’ve been exposed to enough of it in the psych ward to know its capacity for harm. A wish to be able to read minds is exactly the kind of wish that the devil loves to grant. Yet, speech bias does act as an impediment towards peace and understanding between people in conflict. If we could all just plug our brains into a global neural network where ideas and information were exchanged freely, wouldn’t the world be a better, more peaceful place?

Wait a minute, that sounds an awful lot like the blogosphere.

Wednesday, December 06, 2006

The power to reassure

While covering the ICU (intensive care unit) earlier this year, I received my first call on the pacemaker hotline. This hotline service is offered by one of the hospitals at which I rotate to patients who have pacemakers, so that when they have emergency issues they can call in and transmit electrical tracings for interpretation. I’m not sure who staffs the line during the daytime, but at night and on weekends, it falls to the ICU resident to field the calls and give advice.

Let me just pause for a moment and note that the whole concept of a pacemaker hotline, as great as it sounds, is probably somewhat flawed. Pacemakers, it so happens, are rather complex machines; they are the gadgets of electrophysiologists, physicians so specialized that they have completed not one but two fellowships after their internal medicine residency. In contrast, I have not even completed half of my residency, which to me suggests that I have about as much business interpreting a pacemaker tracing as I do trying to repair a malfunctioning jet engine before takeoff.

Despite these reservations, I nonetheless was the on-call ICU resident, and the nurses were telling me that a little old lady was on the other end of the pacemaker hotline, expectantly awaiting my advice.

“Hi, this is Dr. C,” I said.
“Hello, doctor.”
“How can I help?”
“Well, doctor, I have been having stomach pains most of the afternoon. I think it might be related to something I ate for lunch, but I thought I would see if it could be my pacemaker.”
“Hmm, are you having any chest pain?”
“Palpitations or shortness of breath?”
“No, doctor.”
“On a scale of 1 to 10, how bad is the pain?”
“About 4 to 6.”
“ And it started after lunch?”
“Yes, it started about an hour after lunch, and has been going on for a couple of hours.”

I looked at the tracing that had been placed in my hands. It looked ok to me, but then again, what did I know? The tracing only showed one lead, as opposed to the twelve-lead EKGs or two-lead telemetry strips with which I was familiar, and it didn’t specify which lead it was. The heart rate was normal, though, and the pacemaker seemed to be pacing appropriately. I stared at the thing for a minute or two, and I must have appeared to be somewhat confounded, because one of the more experienced ICU nurses came over to me, and winking knowingly, said, “Just send her to the ER.”
“Is that what the residents usually do?” I asked.
She nodded. “Yeah.”
“But I think she just has a stomachache.”
She shrugged helplessly.

“Miss, your pacemaker tracing looks fine. I’m not sure why you’re having abdominal pain, but I don’t think it’s related to your pacemaker,” I said. “If the stomach pain is bothering you, I suggest that you go to the ER to be evaluated.”
“Ok, doctor, but I think I’ll just wait it out then. I’m sure it will get better in a little bit. Thank you very much.”
“All right, you’re welcome, have a good night.”

I hung up the phone feeling pleased with myself; I had just saved this lady a trip to the ER, which would have been a great inconvenience to her and definitely ruined the rest of her night. I started jotting down a note in the logbook. Suddenly a pang of doubt hit me – was I really sure that she was ok? The cardinal rule of medical hotlines is to always send the patient to the ER, no matter what the complaint. Not only had I broken that rule, I had taken a stand on my own and would be personally responsible for anything that might happen. I thumbed through the other entries in the logbook – one after the other, the entries read, “patient agreed to call 911 for an ambulance,” “patient to leave immediately for ER,” “patient waiting for EMS.” Uh-oh. I looked again at the tracing – wait a minute, this tracing wasn’t completely normal, one of the waves had an abnormal shape. It was probably just her baseline waveform, and not really a reason to be having abdominal pain, but was I really willing to put my neck on the line?

The same ICU nurse, who could sense my doubt, repeated, “Just send her to the ER.”
“What do you think, do I need to call an ambulance for her or should I let her drive herself?” I had no experience in this.
“Maybe somebody can take her. Or she can call an ambulance herself.”

I called her back. “Hi, this is Dr. C again. I was just looking at your tracing further, and I decided that based upon the tracing, I can’t really be certain that nothing is going on with your heart. I have to strongly recommend that you go to the ER to be evaluated. Do you think there is someone who can take you?”
“No, doctor, I’m sure that I’m fine. The nearest emergency room is an hour’s drive away, and there’s nobody to take me.”
“Well, can’t you call an ambulance?”
“No, doctor, really, I’m going to be ok.”
“The problem is, without being able to see you and evaluate you, I can’t be sure that you aren’t having a heart attack.”
“But doctor, I’m not having any chest pain.”
“Yes, well, sometimes a heart attack presents unusually, as abdominal pain, or as a variety of other symptoms. I just can’t really tell from here. I have to strongly recommend that you go the ER for evaluation.”
I held back from playing my ultimate trump card, that is, threatening her that she could die, since I was pretty sure she just had a stomachache.
“I understand doctor, but I’m just going to wait a little bit and see if it doesn’t get better.”

This time I hung up the phone feeling deeply unsatisfied. I had set my imagination in motion, and it was leading me in directions I didn’t want to go. The abnormal electrical wave on the lady’s pacer tracing started glaring at me, mocking me. Did I need to absolutely insist that she go to the ER? There was only one thing to do: I paged the cardiology fellow.

“Hey, this is Wyatt, the ICU resident, I’m sorry to bug you, but I was wondering if you could look at a tracing from the pacemaker hotline. It’s a little old lady having abdominal pain, and I think the tracing looks ok, but I’m not entirely sure how to interpret it.”
I faxed him the tracing. He agreed, the tracing was fine, but he thought she should go to the ER to have her abdominal pain evaluated.

At least now I could let the matter rest. I didn’t need to call her back to insist upon anything – I would just let my “strong recommendation” to go to the ER stand. I felt cuckolded, though; this was not why I had become a doctor. A patient had called for reassurance, one of the greatest things that a physician can offer, but I had only heightened her anxiety. I had said and done things that I didn’t believe simply because of fear of liability. In fact, in the end I had made it my chief objective to ensure that she received absolutely no comfort from talking with me. Defensive medicine, we call it. A result of our hyper-litigious society, it is one of the most destructive forces in medicine today, paralyzing our ability to care for our patients if we let it. In this case, my lady would have been better off not speaking to me at all.

18:40, that was the low point of my call night. Three hours later, after I had resuscitated a coding patient, set him up on a mechanical ventilator, thrown in a subclavian central venous line, and tucked him in for the night, I felt a whole lot better. I was a doctor again.