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Sunday, February 23, 2014

The Hospital Dependent Patient--some people will be in and out of the hospital despite our best efforts to make them well

This week the New England Journal of Medicine published an article by David Reuben MD and Mary Tinetti MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these "hospital dependent" patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, usually also poor and with home situations unequal to their vast medical needs. Drs. Tinetti and Reuben are apparently studying these patients, thinking about solutions and now focusing us on this special population.

Hospitals potentially risk not being paid for patients who return to the hospital with new or persistent diseases within a short time of discharge. (I wrote an article on the history of this several months ago which points out some of the same issues that Dr. Reuben and Dr. Tinetti mention as well as how this fits in with the history of Medicare. Not as dry as it sounds. You should check it out.) Physicians who readmit patients after less than a 30 day hiatus are made to feel that they have participated in some sort of failure of management. Sometimes they have, but sometimes that isn't the case at all. If a patient is readmitted with an illness that is still troublesome, but clearly improving out of the hospital, for which the patient has visited the emergency department only for reassurance, this is a failure of management, due to unfamiliarity with the patient's history, often because the doctors in charge haven't really read the chart, reviewed the history or talked to the patient. If a patient is readmitted because treatment has lead to a preventable complication, that is a failure of management. If the readmission could have been prevented by a timely visit to an outpatient physician, this is a system failure of some kind and potentially avoidable. If the patient returns, however, because he or she is just too sick and fragile to remain well outside of a hospital, there is no failure, other than that expectation of success was overly optimistic.

The reason that we have hospital dependent patients is that our hospitals are really quite good at keeping people alive, even when they are balanced on a knife edge of medical stability. Twenty-four hour attentive nursing and frequent visits by physicians, respiratory and physical therapists, dietitians, patient educators and social workers along with spare-no-cost life saving technology is wondrously effective at shoring up the nearly dead. For many people, though, life without all of this is hard or impossible, so after a few days at home or in a nursing home, they will return to the hospital to be saved again.

Solutions involve difficult decisions. Is it worth the staggering amount of cash it takes to keep people in marginal health marginally healthy? How can one enter into the discussion of allowing natural death with a patient who feels mostly pretty good with ordinary hospital care? Herein lies the fallacy: once we get to this point, hospital dependency, it is hard to back off. The trick is to not get there in the first place.

Most people who are independent and in full possession of their faculties do not want to be a burden on others. There are many moments between this point and full dependency when decisions could be made to withhold life prolonging medical care, and it is important that we present patients with these options without making them feel that they need to at least try what we have to offer. Although we as physicians are becoming more accepting of withdrawing life support or at least not intensifying it as people become desperately ill, most of us feel justified in allowing natural death only in people who have become truly miserable. Our patients, however, would usually prefer not to be truly miserable ever.

Many of our hospital dependent patients have survived some last ditch attempt at keeping them alive. Given the opportunity to do it all again, from the standpoint of their well selves, many would say no.  It is interesting, though, that from the standpoint of being rescued and now dependent, many patients will continue to undergo painful and progressively disabling medical treatments until at last nothing will work.

I'm wondering if it is possible to end our love affair with medicine that defies death in our waning years. Might it be acceptable, at least sometimes, to allow our patients to die without a diagnosis? No cause of death. Death certificates could say "old age" or "natural causes" without further clarification. When death comes knocking, sometimes, if the time is ripe, we might let him in the front door, bid our loved ones goodbye and depart. Or have we as a society really decided that lengthening life is pretty much always a good thing? If we have, hospital dependent patients will be increasingly part of our jobs. Shaming ourselves when they are readmitted is misguided and very unlikely to change anything.

Saturday, February 22, 2014

Requiem for ABC David.

When I first learned to take care of patients in the hospital, as a third year medical student, we used a mnemonic to help us remember what to order when a patient was first admitted. Patients would come in to the hospital from a doctor's office or from the emergency room and the nurses needed a set of orders to know what to do for the patient. The mnemonic we used was "ABC DAVID." This is how it worked:

  1. Admit: to medical surgical unit
  2. Because: diagnosis--Congestive heart failure
  3. Condition: guarded
  4. Diet: sodium restricted
  5. Allergies: no known drug allergies
  6. Activity (sorry, 2 A's): bedrest with bathroom privileges
  7. Vital signs: every 4 hours while awake
  8. Investigations: chest x-ray, morning labs - chemistry panel and blood count
  9. Drugs: digoxin, a diuretic, potassium, a beta blocker, maybe insulin or blood pressure medications, acetaminophen for pain, something mild for sleep, if needed.
It worked pretty well. It did allow me to forget certain things that I really didn't want to forget, like having the nurses measure accurate intake and output (food, water, IV fluids, poop, pee and vomit), care of catheters or nasogastric tubes, but it made sure that I didn't forget the main things.

Today I admitted a patient with congestive heart failure and used our hospital's brand new computerized order entry system with its brand new congestive heart failure admission order protocol. It's huge compared to ABC DAVID, who seemed like a strapping lad a mere quarter of a century ago. It includes the medications that experts have determined from large studies to be necessary for optimal treatment of congestive heart failure, the tests that must be done to adequately diagnose congestive heart failure, plus the other things that we think should be done on everyone who is admitted to the hospital including vaccination for flu and pneumonia, smoking cessation, prevention of blood clots in the legs, plus numerous medications that patients are felt to need even if they don't take them at home, including laxatives, sedatives and nicotine replacement. I must use my rudimentary knowledge of hospital billing to characterize the patient as being an inpatient or on observation. End of life wishes must be documented. Also, of course, ABC DAVID is buried inside the order set.

Even though the computer has various habits that I find irritating, like wanting medication orders to be written in a specific way and notifying me of medication interactions that I am already aware of or which are of no clinical significance, I was grateful to have a way to remember all of this stuff that is, apparently, important and necessary. My brain is too small to hold all of these orders and even too small to hold a mnemonic large enough to remind me of all of these things. Orders are different, of course, for congestive heart failure and community acquired pneumonia, for hip fractures and bowel obstructions and for exacerbations of chronic obstructive lung disease. If I made room in my mind for all of this stuff, I'm sure I would have to jettison something that is far more precious.

It is concerning, at least a bit, to be so dependent on either a computer or a printed cheat sheet to initiate treatment for patients. Physicians being trained now don't even have a mnemonic to fall back on, and I imagine that their brains are perhaps like giant card catalogs without any of the books in the library. This, of course, completely labels me as being nearly senile, since card catalogs only exist in primitive societies and old peoples' memories. (I can still evoke that particular wood and paper smell as I type the words "card catalog.") But unless physicians become familiar with techniques of advanced memory training like the ancient Greeks used for reciting epic poems, there is just too much to know in medicine. We must walk around with some of the vast amount of information that makes up our field of knowledge in order to deduce things, make connections, create solutions to complex problems, but we need to be selective. It is possible to design orders for each patient based upon disease principles and knowledge of hospital processes, recent research and individual patient characteristics. This might be better for patients, but only if we are in top form as we write them. Patient safety advocates favor order forms, for good reason, since I and my fellow physicians can certainly not guarantee that at any given moment we will be in top form.

As I remember ABC DAVID and the days of simpler medicine, it is with the bittersweet regret that makes the past look preferable to the present regardless of whether that is in any way accurate. I would like medicine to be less complicated, and perhaps it will be if we rein in our excesses. But while patients continue to be on too many powerful medications and too many expensive and potentially hazardous tests and procedures are part of everyday practice I am grateful for preprinted order sheets and even computerized order entry when it's not too bug infested. I have found ways to be creative and innovative and to personalize my care for patients without excessive hindrance by protocolized treatment for high profile diseases. If the powers that be want me to remember to vaccinate and provide smoking cessation information to my patients as I am submerged in their acute, pressing and life threatening immediate needs, I thank whatever inanimate order generator that will relieve me of that burden.

Wednesday, February 12, 2014

Mammograms don't help--and the dog that didn't bark in the night

In the short story "Silver Blaze" by Sir Arthur Conan Doyle, Sherlock Holmes remarks that it was very curious that when a race horse disappeared and its trainer appeared to have been murdered, the dog was not heard to bark. Dogs are supposed to bark when odd things happen in the night. If they don't, it means something.

Today Reuters commented upon the most recent article in a series over several years showing evidence that mammograms do not reduce death from breast cancer. Although this is not actually a new finding, it is still big news in the US where the wisdom of having regular mammograms is rarely questioned. In my junk email folder I get commentary on the most influential news from medical meetings and journals from organizations such as Medscape and Internal Medicine News, organizations primarily funded by drug and device manufacturers, but also by other aspects of the business of medicine. These organizations successfully take it upon themselves to educate physicians via email communications and throwaway journals. Most of us would never believe information directly given us by companies that make a profit off of our activities, but we still read the headlines and article links these news services put in front of us. This means that those companies have a powerful influence on what medical news physicians read. There was no mention of this new article by these proprietary news organizations, despite the fact that it was headline news at Reuters and the New York Times.

The Canadian Breast Cancer Research Initiative and 9 other primarily cancer research organizations funded this study, published this week in the British Medical Journal. It looked at nearly 50,000 women ages 40-59, half of them randomized to be offered yearly mammograms and half to clinical breast exams alone. These two groups were followed for 25 years to look for differences in mortality from breast cancer. There was no difference in mortality. If doctors paid attention to this, it would follow that we would not universally recommend mammograms at all. There may be subsets of women who will benefit from mammogram screening, but it may also be that bad breast cancers kill people, and discovering them a little bit earlier by mammograms rather than when they can be felt on a clinical exam, and removing them just that little bit earlier doesn't change this.

So why the spotty news coverage? I saw the Reuters article on Google News, as a top story, then researched the actual study a bit, then went back to find the article on Google News and it was gone. It was replaced by a study that said that removing both breasts if you have the BRCA breast cancer gene mutation saves lives, even if one of those breasts has no cancer. I had to go to my history to find the Reuters article again. It was nowhere on Google News. Suppressing a story like this until people with a stake in the outcome have their official responses polished may have a profound effect on maintaining the multi-billion dollar revenue associated with regular screening mammograms.

Am I being a paranoid conspiracy theorist? Perhaps. But I am hearing a strange lack of anything about how maybe we don't need to be doing mammograms.

Friday, February 7, 2014

Sick patients with chronic diseases and the wisdom of Dr. Bernard Lown

I have been doing admitting shifts at a large hospital, as hospitalist. It is flu season, so volumes are large. Even people without the flu are sick. It often happens that way. And they are so very sick!

The thing about the very sick patients I see is that they are generally what might be called "medical train wrecks." They are very sick because they have had interventions over the years that have caused them to be dependent on more medical interventions. In some cases this means that they are alive when they would be dead otherwise, and in some cases medicine has allowed them to make more terrible choices in their lives and be subsequently more miserable than they would have been if forced to face the logical consequences of their behaviors. Often these two stories are played out in the same people. It is hard to take care of these people because they have had so much done to them, have taken so many medications, had so many complications that the landscape of caring for them is like a mine field.

I saw a former smoker whose lung disease was so severe that he couldn't stay out of the hospital for more than a week, and lived at a nursing home. His disease process had progressed to the point that he no longer was able to breathe off the carbon dioxide in his system and when this would build up he would become more sleepy and breathe even less. He also was prescribed strong opiate pain medications for his back and neck pain, worse because he stayed in bed all day and struggled to breathe, but which made him sleepy enough to not move or cough or breathe adequately. He was aware of how this worked, but unable to imagine life without pain medications for his numerous aches. He had been discharged from the hospital only a week before, on intravenous antibiotics through his nursing home which he was still getting when he returned. I suspect he had been on antibiotics for much of the last year, and these were the ones designed for resistant bacteria, which he probably harbored. I was probably the 100th doctor who had seen him and it was unclear what intervention I could make that would improve things at all.

I saw two people who were immigrants from very poor countries, but now in the US for decades. Neither of them could tell me about the medical history of their parents because their parents had never seen doctors. Both had end stage kidney failure, one had received a kidney transplant after 8 years of dialysis, certainly well over a million dollars of medical costs in 10 years. The US takes special care of patients whose kidneys have failed, usually finding money to pay for their expenses either from Medicare or Medicaid funds, or often both. The patient's own funds are almost always completely sapped as well, but no individual can afford long term kidney replacement therapy, which can run thousands of dollars a week, even without the decompensations that are so common in such patients. These were interesting people, but they had suffered physical pain as well as the shame of uselessness and dependence as America's often generous and certainly technological medical system kept them alive.

It may not sound like it, but I do respect these people and enjoy the opportunity to work with them. I also feel conflicting loyalties, because these, my patients, are part of a dynamic that wrecks opportunities for other people to stay healthy and alive. I just read an article from the US News describing how healthcare costs, specifically insurance for city employees in this case, resulted in a community budget that couldn't afford after school programs and struggled to support even minimal recreation programs. School kids collected thousands of pounds of old shoes to raise $6000 to save their after school activities. It is the work of an hour to spend $6000 in health care.

Many of the patients who find themselves in these dependent relationships with the medical profession are poor or old or otherwise disadvantaged, leaving them less able to make decisions about their lives and less able to advocate for their own wishes with healthcare providers. They are carried along in the flow of "this is what we do with people with your condition." Once saved by medicine, it is very difficult to take a different course.

I was feeling kind of sad about all of this when I found something in my email that cheered me up.
Unsolicited, in my primary inbox, was a letter from the Lown Institute. In the email they linked the article I mentioned a few paragraphs up about the school kids who had to raise money for after school programs because their community spent so much money on healthcare. I went to their website and was surprised to see that the group is full of super high functioning people interested in health, mostly doctors but also public health people and even the founder of the Panera Bread Company. Per their website "We seek to create and foster a new social contract between the profession of medicine, the business of healthcare, and civil society." What this appears to mean is that they are working with powerful people to move medicine in the direction of providing thoughtful and considerate care for the human beings who are our patients. The founder, Dr. Bernard Lown, is originally from Lithuania and practiced all of his life in the US. He invented the defibrillator, which has saved countless lives of patients who lose circulation suddenly because of a heart arrhythmia. He also won the Nobel Prize for starting the physicians group that became Physicians for Social Responsibility, which advocated against nuclear weapons. He is a well spoken advocate for really good medical care, meaning listening to patients, examining them and not doing stupid and harmful excessive testing or treatment. I would happily sit at his feet. He continues, in his 90s, to advocate for the right stuff, and I could probably  simply link to his article which is beautifully steeped in over half a century of being a doctor and now a patient, rather than writing anything at all. 

It is heartening for me to see that there are good, kind people with excellent minds who are outspoken and influential at the highest levels of discussion. People like Dr. Lown remind us to be doctors rather than highly educated data managers and test orderers.