As I walk out of the building, I wonder if I will ever step through these doors again. I feel a faint ache in my chest and my eyes tear up. We had a few good years-the building and I.
How many mornings had I rushed in at 6AM to evaluate and ailing patient? How many afternoons had I sat at the nursing station writing in charts and chatting with residents and staff?
My letter of resignation was an abrupt and unexpected end to an emotional connection.
I could no longer come to the facility.
*
There was a time, in my career, where I pictured myself a superhero. I swooped into patients rooms in the nick of time. It was a one sided arrangement.
As I matured as a physician, I realized that the doctor-patient relationship is much more complicated. It's more like a dance. Sometimes our steps are in unison. Other times it is as if we are listening to completely different music. But it's two sided. Like most relationships it is messy and complex. Each party has both needs and gifts that require nurturing.
How could I not be changed by my years at the nursing home? I think of the resident who would accost me while I was charting at the desk. How often we talked about baseball and the Cubs. I never had the courage to tell him that I knew nothing of such things. But with time, I came to expect this camaraderie. I learn to look forward to these encounters.
*
It's hard for a physician, nay a person, to admit that we can no longer meet other people's needs. Or better yet, that meeting these needs will encroach on our own.
As we grow and change, we take on these transitions with little thought. We leave practices and hospitals. We move to different cities or change careers. And for the most part, we are oblivious to all that we have left behind.
But today I will be cognizant. I will say goodbye to years of hard work and countless relationships built on blood, sweat, and even tears. I will not be ashamed of my sadness, nor deny that I am leaving behind some who truly need me.
I will also admit that my absence will not be a contradiction to the fact that I need them too. I will not pretend that this is just another day. I will not pretend.
That breaking up isn't hard to do.
Saturday, October 29, 2011
Wednesday, October 26, 2011
Humanity
I'm not sure when I lost my humanity-at least for the most part. Maybe it was the hazing in medical school or the unending nights of residency. I prefer to speculate it was the dull thud of yet another pile of papers dropped on my desk.
Whatever the excuse, it happened. The soft, compassionate, eager student who started this journey is morphing. My skin withers and thickens into sheets of heavy chain mail. My eyes turn a colder shade of grey. My hands become dry and leathery in the midst of the frosty Chicago weather.
My body and soul adapt to form a protective shell. My heart battered and bruised beats in it's restless cage.
But sometimes, for just a moment, I remember the former strength of my innards. How my heart stood front and center. Occasionally knocked by the harshest of realities but never backing down.
Those days seem so far away now.
*
I gently rock back and forth as I stand at the nursing station. Three racks of charts rest beside me. Every few minutes I close one chart, place it back in it's holder, and pull another. I am acutely aware of the ticking clock on the adjacent wall.
My billing sheets collect dust in a pile next to me. I'm tired. For two hours I roamed the hall of the nursing home, interviewing its inhabitants. I put out fires. I calmed angry family members. And I am about to finish documenting, when a young woman walks up to the desk and waits quietly for my attention.
Are you Doctor G? I was wondering if you could come talk to my father.
I glance at the chart the nurse placed on the counter next me and feel an odd sense of relief.
Your father is not my patient. You should call his doctor.
She taps her feet impatiently and looks slightly annoyed.
Well the nurses told me you're covering for Dr. K who is out of town.
I vaguely remember that I offered to manage Dr. K's patients while he is gone. My heart falls. I'm already late and the last thing I want to do is walk into the care of a train wreck.
The woman watches my response closely. She senses hesitation. She's angry
Look! If you don't want to help...
She turns away and stalks down the hallway.
*
I walk into the room with my tail tucked between my legs. A kind elderly man lies in the bed in the center of the room. He is surrounded by his wife and daughters who fawn over him to adjust his bedding. None of the fangs that I witnessed earlier are now apparent.
Their needs are minimal. A simple explanation. Some interpretation of tests. Mostly they are looking for attention. They search for a sign that someone is commanding the ship through the relentless tempest of illness that they bravely face.
And I remember back to a time before my mind was clouded by all this "education". When I would give myself freely to sit with an ailing patient and provide the sort of "doctoring" that now has been squeezed out of me.
I started on this path to provide service to my fellow man.
How have I wandered so far off course?
Whatever the excuse, it happened. The soft, compassionate, eager student who started this journey is morphing. My skin withers and thickens into sheets of heavy chain mail. My eyes turn a colder shade of grey. My hands become dry and leathery in the midst of the frosty Chicago weather.
My body and soul adapt to form a protective shell. My heart battered and bruised beats in it's restless cage.
But sometimes, for just a moment, I remember the former strength of my innards. How my heart stood front and center. Occasionally knocked by the harshest of realities but never backing down.
Those days seem so far away now.
*
I gently rock back and forth as I stand at the nursing station. Three racks of charts rest beside me. Every few minutes I close one chart, place it back in it's holder, and pull another. I am acutely aware of the ticking clock on the adjacent wall.
My billing sheets collect dust in a pile next to me. I'm tired. For two hours I roamed the hall of the nursing home, interviewing its inhabitants. I put out fires. I calmed angry family members. And I am about to finish documenting, when a young woman walks up to the desk and waits quietly for my attention.
Are you Doctor G? I was wondering if you could come talk to my father.
I glance at the chart the nurse placed on the counter next me and feel an odd sense of relief.
Your father is not my patient. You should call his doctor.
She taps her feet impatiently and looks slightly annoyed.
Well the nurses told me you're covering for Dr. K who is out of town.
I vaguely remember that I offered to manage Dr. K's patients while he is gone. My heart falls. I'm already late and the last thing I want to do is walk into the care of a train wreck.
The woman watches my response closely. She senses hesitation. She's angry
Look! If you don't want to help...
She turns away and stalks down the hallway.
*
I walk into the room with my tail tucked between my legs. A kind elderly man lies in the bed in the center of the room. He is surrounded by his wife and daughters who fawn over him to adjust his bedding. None of the fangs that I witnessed earlier are now apparent.
Their needs are minimal. A simple explanation. Some interpretation of tests. Mostly they are looking for attention. They search for a sign that someone is commanding the ship through the relentless tempest of illness that they bravely face.
And I remember back to a time before my mind was clouded by all this "education". When I would give myself freely to sit with an ailing patient and provide the sort of "doctoring" that now has been squeezed out of me.
I started on this path to provide service to my fellow man.
How have I wandered so far off course?
Tuesday, October 25, 2011
Actively Dying
The group of students walking behind me move uneasily through the bustling hospital halls. Their crisp clean coats stand in stark contrast to the faded linoleum and stained wallpaper. Doctors and nurses dart quickly to avoid slowing down behind the ambling herd.
I pause for a moment at the end of the hall, think better of it, and walk on. I turn quickly toward the group as my legs propel me forward mechanically. Our next stop is just three doors away. I check to make sure the hallway is empty before addressing the group.
I think we'll skip room 214. She's "actively dying."
A few steps later, it dawns on me that such a term is likely confusing to a third year student. I stop abruptly in front of our next patients room.
So who can tell me the definition of "actively dying"?
The row of faces look up quizzically, but I am already lost in thought.
*
My mom's voice sounded shaky over the phone. I could hear my grandmother breathing heavily in the background. Her silence spoke volumes. I adjusted the receiver and took a deep breath.
How's she doing?
My mom's answer was almost imperceptible. I felt, for a moment, like I was talking to a child.
Okay.
I strained to interpret her uneasiness as I calculated the distance between St. Louis and Chicago. If I left immediately, I could reach the assisted living in six hours.
Is she still talking to you?
Instead of answering, my mother lifted the phone to my grandma's ear and coaxed her to speak. I listened to each struggling gasp. The prolonged breaths were punctuated by pauses.
My mind clicked. As a second year resident, I'd dealt with this before. I slammed down the phone and rushed to my bedroom to pack a few things before leaving the house.
The roads were dark as I sped down the highway.
Time was running out.
*
Six hours later, I walked into my grandmother's room. I was oblivious to the grime and sweat caked on my body. I had driven all night. I knelt next to the bed and placed her hand in mine. My mother and father sat quietly in the corner.
Her breathing had slowed since the night before. The pauses were more apparent. I leaned over and kissed her forehead. I whispered into her ear.
It's OK. You can go now!
I placed the radio on the nightstand and put on the My Fair Lady CD.
Grandma's chest moved up and down slowly with the rhythm. Each rise and fall more gentle till the energy in the room palpably changed.
Her body was still.
Her soul had left us.
*
After a reflective moment, I answer my own question.
"Actively dying" is the final phase of life. The short interlude in which the dying process takes place. It often lasts between twelve and twenty four hours. Patients are usually unconscious and exhibit cheyne stokes breathing.
I can see the puzzlement wash over the student's faces. A few raise their hands as if we are in a classroom. One speaks up.
So what do we do when this happens?
The first thing that comes to mind is my mom's face. She still can't talk about that day without breaking into tears.
We comfort the family.
They are the ones who will carry the scars.
I pause for a moment at the end of the hall, think better of it, and walk on. I turn quickly toward the group as my legs propel me forward mechanically. Our next stop is just three doors away. I check to make sure the hallway is empty before addressing the group.
I think we'll skip room 214. She's "actively dying."
A few steps later, it dawns on me that such a term is likely confusing to a third year student. I stop abruptly in front of our next patients room.
So who can tell me the definition of "actively dying"?
The row of faces look up quizzically, but I am already lost in thought.
*
My mom's voice sounded shaky over the phone. I could hear my grandmother breathing heavily in the background. Her silence spoke volumes. I adjusted the receiver and took a deep breath.
How's she doing?
My mom's answer was almost imperceptible. I felt, for a moment, like I was talking to a child.
Okay.
I strained to interpret her uneasiness as I calculated the distance between St. Louis and Chicago. If I left immediately, I could reach the assisted living in six hours.
Is she still talking to you?
Instead of answering, my mother lifted the phone to my grandma's ear and coaxed her to speak. I listened to each struggling gasp. The prolonged breaths were punctuated by pauses.
My mind clicked. As a second year resident, I'd dealt with this before. I slammed down the phone and rushed to my bedroom to pack a few things before leaving the house.
The roads were dark as I sped down the highway.
Time was running out.
*
Six hours later, I walked into my grandmother's room. I was oblivious to the grime and sweat caked on my body. I had driven all night. I knelt next to the bed and placed her hand in mine. My mother and father sat quietly in the corner.
Her breathing had slowed since the night before. The pauses were more apparent. I leaned over and kissed her forehead. I whispered into her ear.
It's OK. You can go now!
I placed the radio on the nightstand and put on the My Fair Lady CD.
Grandma's chest moved up and down slowly with the rhythm. Each rise and fall more gentle till the energy in the room palpably changed.
Her body was still.
Her soul had left us.
*
After a reflective moment, I answer my own question.
"Actively dying" is the final phase of life. The short interlude in which the dying process takes place. It often lasts between twelve and twenty four hours. Patients are usually unconscious and exhibit cheyne stokes breathing.
I can see the puzzlement wash over the student's faces. A few raise their hands as if we are in a classroom. One speaks up.
So what do we do when this happens?
The first thing that comes to mind is my mom's face. She still can't talk about that day without breaking into tears.
We comfort the family.
They are the ones who will carry the scars.
Monday, October 24, 2011
Memories Of My Father
So it happened again the other day. I was admitting a patient with kidney failure and his potassium came back at 6.9. I quickly got on the phone and dialed the patient’s nephrologist. He was an older gentleman who I rarely worked with. His secretary kindly took my information and replied,
“OK Dr. Grumet, I'll let him know you’re holding”.
After a minute he picked up the phone:
"Hello....Jerry?”
It took me aback for a moment although it shouldn’t have. It’s already happened a few times since I moved to Highland Park.
“High Dr. H, this is Jordan Grumet. Jerry (Gerald) was my father”
"Of course, Of course, Jerry died years ago. I knew your father well. Hell of a physician. We worked together at Northwestern”
Although my father died in the early eighties, i’t sometimes seems that he is still alive and well, roaming the halls of the hospital. No matter where I practice, someone goes out of their way to tell me what a wonderful physician he was. One day it will be a colleague and the next a nurse. A few of my patients even knew him.
And yes, I still get called “Jerry” all the time. I have mixed feelings about this. On one hand, I am extremely proud that twenty plus years after his death his memory is still strong. That he was a great physician and people carry his kindness and wisdom with them. On the other, I'm getting to the point in my career where I am no longer content to be known as the son of a great physician. Sometimes I want to be acknowledged for my own achievements and merit.
But the truth is, when I reread the last paragraph, I guess I'm lying to myself. Because what really burns is that all these people have a piece of my father that I will never own. They knew him as a physician.
And there have been times when I really needed to know that aspect of him. When I was struggling in residency after countless sleepless nights, I could have used his encouragement. When I did my best and watched my patients die anyway, I so yearned for his support. When I became disillusioned with medicine and felt like leaving, it would have been helpful to know that he went through the same thing. And when a colleague accidentally picks up the phone and calls me “Jerry” it would be nice to hear his laughter as he slaps me on the back and exclaims,
“if only I was half as good a physician as you are at your age!”
Because at the core, stripped of the years of education and medical degrees, I am still just a little boy trying his best to gain the respect and love of his father.
And sadly, I am all to aware, that thirty years after his death...
that is no longer possible.
“OK Dr. Grumet, I'll let him know you’re holding”.
After a minute he picked up the phone:
"Hello....Jerry?”
It took me aback for a moment although it shouldn’t have. It’s already happened a few times since I moved to Highland Park.
“High Dr. H, this is Jordan Grumet. Jerry (Gerald) was my father”
"Of course, Of course, Jerry died years ago. I knew your father well. Hell of a physician. We worked together at Northwestern”
Although my father died in the early eighties, i’t sometimes seems that he is still alive and well, roaming the halls of the hospital. No matter where I practice, someone goes out of their way to tell me what a wonderful physician he was. One day it will be a colleague and the next a nurse. A few of my patients even knew him.
And yes, I still get called “Jerry” all the time. I have mixed feelings about this. On one hand, I am extremely proud that twenty plus years after his death his memory is still strong. That he was a great physician and people carry his kindness and wisdom with them. On the other, I'm getting to the point in my career where I am no longer content to be known as the son of a great physician. Sometimes I want to be acknowledged for my own achievements and merit.
But the truth is, when I reread the last paragraph, I guess I'm lying to myself. Because what really burns is that all these people have a piece of my father that I will never own. They knew him as a physician.
And there have been times when I really needed to know that aspect of him. When I was struggling in residency after countless sleepless nights, I could have used his encouragement. When I did my best and watched my patients die anyway, I so yearned for his support. When I became disillusioned with medicine and felt like leaving, it would have been helpful to know that he went through the same thing. And when a colleague accidentally picks up the phone and calls me “Jerry” it would be nice to hear his laughter as he slaps me on the back and exclaims,
“if only I was half as good a physician as you are at your age!”
Because at the core, stripped of the years of education and medical degrees, I am still just a little boy trying his best to gain the respect and love of his father.
And sadly, I am all to aware, that thirty years after his death...
that is no longer possible.
Saturday, October 22, 2011
Ode To The Computer Guy
The computer guy (our trainer) is starting to look stressed. The sweat roles down his forehead as he hunches over the lab top. A cell phone is perched between his shoulder and ear. A line of people are standing behind him. He tries to inconspicuously look at his watch while he waits for a response on the telephone line. Only a few more minutes till quitting time.
Our "go live" has ended horribly. It's the close of day two, and there are still major glitches in the system. The eprescribe functionality is missing in action. Scanning of external documents is restricted and the auto fax is nonoperational.
My partner, who hadn't bothered to peruse the online learning modules, runs after the trainer between each patient. He struggles to input precious information that swirls randomly in and out of his consciousness.
My office manager is perturbed. Half the staff aren't up to speed. The other half are threatening to quit.
It's a miracle that any medical care has actually taken place in the last few days.
*
I feel strangely above the fray as I observe the seen unfolding in front of me. I can't help but harboring a touch of scorn for the computer technician.
He thinks he's stressed!
At the moment I have a patient in the nursing home dying of lung cancer. He's in severe respiratory distress. His family crowds around as he struggles to suck short wisps of air through fibrotic lungs. He is like a fish out of water. I order intravenous morphine and ativan around the clock.
A nurse just called to report that my psychotic patient who ripped open his scrotum spiked a fever. A moment ago, the lab informed me that my demented patient with "non cardiac" chest pain has positive markers.
I'm thirty minutes behind in the schedule and my last patient managed to vomit on the medical assistant
Yet, I haven't broken a sweat. I manage these, as well as all other crises, with an air of confidence. This is a typical Friday afternoon. I feel completely at home in the midst of chaos.
*
But maybe I'm not giving the technician enough credit. Maybe he is wiser then I. His job is methodical and orderly. He finishes with one problem, and then moves to the next. At the end of the day he's done.
Physicians, on the other hand, have let their profession get out of hand. We have lost control of our most important commodity-time.
It probably happened decades ago when the pressure of paying for overhead spurred us to become more efficient. Take on more cases. See more patients.
Now we manage thousands of lives. We takes histories, answer overhead pages, and tend to our cell phones simultaneously.
As our heads spin, our hearts palpitate, and our blood pressures rise, we find our internal rhythms changing. We become over-caffeinated. We concentrate intensely in small spurts.
We live in a facebook/twitter society. One blink and everything changes.
But wouldn't it be nice, for once, to be like the computer guy. To greet each patient as if there aren't four other crises or five other people trying to get our attention.
As if the patient sitting in front of us is the only one.
The only one who exists in the world.
Our "go live" has ended horribly. It's the close of day two, and there are still major glitches in the system. The eprescribe functionality is missing in action. Scanning of external documents is restricted and the auto fax is nonoperational.
My partner, who hadn't bothered to peruse the online learning modules, runs after the trainer between each patient. He struggles to input precious information that swirls randomly in and out of his consciousness.
My office manager is perturbed. Half the staff aren't up to speed. The other half are threatening to quit.
It's a miracle that any medical care has actually taken place in the last few days.
*
I feel strangely above the fray as I observe the seen unfolding in front of me. I can't help but harboring a touch of scorn for the computer technician.
He thinks he's stressed!
At the moment I have a patient in the nursing home dying of lung cancer. He's in severe respiratory distress. His family crowds around as he struggles to suck short wisps of air through fibrotic lungs. He is like a fish out of water. I order intravenous morphine and ativan around the clock.
A nurse just called to report that my psychotic patient who ripped open his scrotum spiked a fever. A moment ago, the lab informed me that my demented patient with "non cardiac" chest pain has positive markers.
I'm thirty minutes behind in the schedule and my last patient managed to vomit on the medical assistant
Yet, I haven't broken a sweat. I manage these, as well as all other crises, with an air of confidence. This is a typical Friday afternoon. I feel completely at home in the midst of chaos.
*
But maybe I'm not giving the technician enough credit. Maybe he is wiser then I. His job is methodical and orderly. He finishes with one problem, and then moves to the next. At the end of the day he's done.
Physicians, on the other hand, have let their profession get out of hand. We have lost control of our most important commodity-time.
It probably happened decades ago when the pressure of paying for overhead spurred us to become more efficient. Take on more cases. See more patients.
Now we manage thousands of lives. We takes histories, answer overhead pages, and tend to our cell phones simultaneously.
As our heads spin, our hearts palpitate, and our blood pressures rise, we find our internal rhythms changing. We become over-caffeinated. We concentrate intensely in small spurts.
We live in a facebook/twitter society. One blink and everything changes.
But wouldn't it be nice, for once, to be like the computer guy. To greet each patient as if there aren't four other crises or five other people trying to get our attention.
As if the patient sitting in front of us is the only one.
The only one who exists in the world.
Friday, October 21, 2011
Hospice and The Way Of The Master Diagnostician
I had the privilege of giving the keynote address for the Amedysis Hospice Strategy Summit last week in Louisville, Kentucky. Below find an abridged version of my comments.
Hospice and The Way Of The Master Diagnostician
We are facing a crisis in our healthcare system. If you listen to the politicians, two forces are growing that are diametrically opposed. On one side, the right composed mostly of Republicans. On the other, the liberal left and Democrats.
Although they never seem to agree, if you listen closely, we are all searching for the same thing. Our arguments, when distilled to their basic tenets, are similar.
We have to define the most salient indicators of quality and learn how to motivate our practitioners to adhere to them.
Quality and motivation. It sounds simple. But in reality it is anything but.
*
Defining quality, in our current healthcare system, is often a struggle. If you ask my colleagues what makes a "good doctor", we will likely mumble something about excellent care. But if you push us further, you'll mostly get blank stares.
Our progress, to date, in aspiring towards quality has been limited to measurement of indicators. We ask ourselves over and over again. What are the indicators of optimal care.
Anyone who understands Goodhart's law, however, knows that we are probably off base. Goodhart's law is an economic principal that simply states:
When an indicator becomes a target, it loses its quality as a measure.
A fun example is Soviet Russia. The government tried to incentivize nail factories to create more product by paying personel according to the number of nails produced. The employees ingeniously increased production by thousands a day by making small ineffective nails.
A more sobering example is the four hour pneumonia rule. Researchers found that patients hospitalized with pneumonia who received antibiotics within four hours of admission to the emergency room fared better. But when they incentivized EDs to give antibiotic faster, their were disastrous results. Over use of medications in inappropriate patients caused worse outcomes and higher costs.
This is Goodhart's law.
*
So even if we could identify the indicators of quality health care, how would we motivate our practitioners to follow them?
The government espouses pay for performance and the carrot and stick method. But one wonders if this flies in the face of motivational theory.
Self determination theory says that we shouldn't try to externally motivate behaviors that should be internally motivated. It never works.
Picture growing up in a crowded neighborhood. The kids on the block run roughshod on all the beautiful lawns. One day the smart guy on the corner lot says to the children:
Please....I'll pay you ten dollars a day. Come play on my lawn.
A week later he returns and scolds the children for doing a poor job and decreases their "wages" to five dollars a day. Another week later he returns and tells them he no longer will pay. When he asks them to play on his lawn they smirk. And they never step foot on his grass again!
This story may sound far fetched until you realize that the UK has been using pay for performance since 2000. A study in the British Medical Journal recently found that the carrot and stick method had no effect whatsoever on blood pressure control or hypertension related morbidity and mortality.
It appears that for people to become internally motivated to perform a complicated task, they need to feel autonomous, competent, and connected. Although it sounds hard to believe, having a central authority dictate your actions can have negative effects on such feelings.
*
I have come here today to tell you that we don't know how to measure quality, and even if we did, we are poor at motivating such behavior.
So we might as well give up, right?
Well, I have an idea that there is a better way. It's the way of the master diagnostician.
Our current healthcare model is a biological one. We focus on genes and diseases, symptoms and treatments. The problem is although we are 99.9% similar genetically, each one of us is very different. We react to stress differently. We get sick differently. And we respond to treatment differently.
The master diagnostician not only recognizes the biologic aspects of health, but also understands biologic variability, the psychological, social, and spiritual components of well being. In other words, the master diagnostician excels at giving each individual patient exactly what they need.
Take, for instance, two patients with coronary chest pain. One is fifty five years and otherwise healthy. The other is ninety five and has end stage cancer.
My fifty five year old will get maximal aggressive hospital care. My ninety five year old will get nitro, morphine, and be told to take it easy at home. Both patients will get appropriate care.
There are no quality indicators or carrots and sticks that can easily accomadate both of the above scenarios.
*
The master diagnostician learns to focus on what each patient needs and not necessarily what they want. The thirty year old with constipation does not need a cat scan of the abdomen. He might want it. He might believe that it will be the only way to calm the fear in his heart. But the risks and likelihood of incidentalomas is too great.
The master diagnostician also realizes that medical care has to respect each individuals right to make decisions. Although everyone should get a screening colonoscopy at age fifty, some patients just don't want one. And that's OK as long as full disclosure of risks and benefits has occurred.
The theory is simple. Give people all that medicine has to offer, but also search each patient for what they really need. Patient centered care that is tailored to each individual's circumstances.
*
I believe if we go the way of the master diagnostician we will achieve the penultimate heathcare reform trifecta. We will increase survival, decrease costs, and improve quality.
I not only believe this, I know it.
How do I know it? Because their are master diagnosticians among us who practice truly patient centered care. They are one of a kind, and their numbers are growing.
They are hospice and palliative medicine practitioners.
Hospice medicine is the only field that has resisted getting stuck on biologic necessity, and has learned to evaluate the psychological, social, and spiritual components of health.
To the hospice and palliative medicine team your cancer is only one concern. They also want to control your pain, prepare your family, and even make sure your dog is taken care of after you die. And why do they focus on such inane things....because that's what the patient tells them to. They look to help each and every soul receive exactly what they need.
*
Earlier I boasted that the master diagnostician theory would bring about the healthcare reform trifecta. That longer survival, lower costs, and increased quality of life are achievable.
I you look at recent data, hospice and palliative medicine have conquered all three goals.
Data from a New England Journal of Medicine article from 2010 showed that patients with metastatic lung cancer lived three months longer if given a palliative care consultation at the time of diagnosis. Data out of Duke in 2007 showed that being on hospice saved medicare roughly $2903 per patient. And finally, too many studies to count have shown that people who die in hospice suffer less pain, are more likely to have their needs met, and their families reported calmer deaths.
*
For all these reasons, I believe we are entering the golden age of hospice. These master diagnosticians are standing as shining examples of what we need to achieve to usher in the age of true healthcare reform.
In order for the movement to continue, two obstacles need to be overcome. First we need to rebrand the movement. The term "hospice" is too old and misunderstood. It no longer serves.
Second, hospice and palliative medicine need to become an earlier part of the health care continuum. Too often, they are relegated to "end of life care". The true power lies in early intervention.
Thank you for listening
Hospice and The Way Of The Master Diagnostician
We are facing a crisis in our healthcare system. If you listen to the politicians, two forces are growing that are diametrically opposed. On one side, the right composed mostly of Republicans. On the other, the liberal left and Democrats.
Although they never seem to agree, if you listen closely, we are all searching for the same thing. Our arguments, when distilled to their basic tenets, are similar.
We have to define the most salient indicators of quality and learn how to motivate our practitioners to adhere to them.
Quality and motivation. It sounds simple. But in reality it is anything but.
*
Defining quality, in our current healthcare system, is often a struggle. If you ask my colleagues what makes a "good doctor", we will likely mumble something about excellent care. But if you push us further, you'll mostly get blank stares.
Our progress, to date, in aspiring towards quality has been limited to measurement of indicators. We ask ourselves over and over again. What are the indicators of optimal care.
Anyone who understands Goodhart's law, however, knows that we are probably off base. Goodhart's law is an economic principal that simply states:
When an indicator becomes a target, it loses its quality as a measure.
A fun example is Soviet Russia. The government tried to incentivize nail factories to create more product by paying personel according to the number of nails produced. The employees ingeniously increased production by thousands a day by making small ineffective nails.
A more sobering example is the four hour pneumonia rule. Researchers found that patients hospitalized with pneumonia who received antibiotics within four hours of admission to the emergency room fared better. But when they incentivized EDs to give antibiotic faster, their were disastrous results. Over use of medications in inappropriate patients caused worse outcomes and higher costs.
This is Goodhart's law.
*
So even if we could identify the indicators of quality health care, how would we motivate our practitioners to follow them?
The government espouses pay for performance and the carrot and stick method. But one wonders if this flies in the face of motivational theory.
Self determination theory says that we shouldn't try to externally motivate behaviors that should be internally motivated. It never works.
Picture growing up in a crowded neighborhood. The kids on the block run roughshod on all the beautiful lawns. One day the smart guy on the corner lot says to the children:
Please....I'll pay you ten dollars a day. Come play on my lawn.
A week later he returns and scolds the children for doing a poor job and decreases their "wages" to five dollars a day. Another week later he returns and tells them he no longer will pay. When he asks them to play on his lawn they smirk. And they never step foot on his grass again!
This story may sound far fetched until you realize that the UK has been using pay for performance since 2000. A study in the British Medical Journal recently found that the carrot and stick method had no effect whatsoever on blood pressure control or hypertension related morbidity and mortality.
It appears that for people to become internally motivated to perform a complicated task, they need to feel autonomous, competent, and connected. Although it sounds hard to believe, having a central authority dictate your actions can have negative effects on such feelings.
*
I have come here today to tell you that we don't know how to measure quality, and even if we did, we are poor at motivating such behavior.
So we might as well give up, right?
Well, I have an idea that there is a better way. It's the way of the master diagnostician.
Our current healthcare model is a biological one. We focus on genes and diseases, symptoms and treatments. The problem is although we are 99.9% similar genetically, each one of us is very different. We react to stress differently. We get sick differently. And we respond to treatment differently.
The master diagnostician not only recognizes the biologic aspects of health, but also understands biologic variability, the psychological, social, and spiritual components of well being. In other words, the master diagnostician excels at giving each individual patient exactly what they need.
Take, for instance, two patients with coronary chest pain. One is fifty five years and otherwise healthy. The other is ninety five and has end stage cancer.
My fifty five year old will get maximal aggressive hospital care. My ninety five year old will get nitro, morphine, and be told to take it easy at home. Both patients will get appropriate care.
There are no quality indicators or carrots and sticks that can easily accomadate both of the above scenarios.
*
The master diagnostician learns to focus on what each patient needs and not necessarily what they want. The thirty year old with constipation does not need a cat scan of the abdomen. He might want it. He might believe that it will be the only way to calm the fear in his heart. But the risks and likelihood of incidentalomas is too great.
The master diagnostician also realizes that medical care has to respect each individuals right to make decisions. Although everyone should get a screening colonoscopy at age fifty, some patients just don't want one. And that's OK as long as full disclosure of risks and benefits has occurred.
The theory is simple. Give people all that medicine has to offer, but also search each patient for what they really need. Patient centered care that is tailored to each individual's circumstances.
*
I believe if we go the way of the master diagnostician we will achieve the penultimate heathcare reform trifecta. We will increase survival, decrease costs, and improve quality.
I not only believe this, I know it.
How do I know it? Because their are master diagnosticians among us who practice truly patient centered care. They are one of a kind, and their numbers are growing.
They are hospice and palliative medicine practitioners.
Hospice medicine is the only field that has resisted getting stuck on biologic necessity, and has learned to evaluate the psychological, social, and spiritual components of health.
To the hospice and palliative medicine team your cancer is only one concern. They also want to control your pain, prepare your family, and even make sure your dog is taken care of after you die. And why do they focus on such inane things....because that's what the patient tells them to. They look to help each and every soul receive exactly what they need.
*
Earlier I boasted that the master diagnostician theory would bring about the healthcare reform trifecta. That longer survival, lower costs, and increased quality of life are achievable.
I you look at recent data, hospice and palliative medicine have conquered all three goals.
Data from a New England Journal of Medicine article from 2010 showed that patients with metastatic lung cancer lived three months longer if given a palliative care consultation at the time of diagnosis. Data out of Duke in 2007 showed that being on hospice saved medicare roughly $2903 per patient. And finally, too many studies to count have shown that people who die in hospice suffer less pain, are more likely to have their needs met, and their families reported calmer deaths.
*
For all these reasons, I believe we are entering the golden age of hospice. These master diagnosticians are standing as shining examples of what we need to achieve to usher in the age of true healthcare reform.
In order for the movement to continue, two obstacles need to be overcome. First we need to rebrand the movement. The term "hospice" is too old and misunderstood. It no longer serves.
Second, hospice and palliative medicine need to become an earlier part of the health care continuum. Too often, they are relegated to "end of life care". The true power lies in early intervention.
Thank you for listening
Thursday, October 20, 2011
We All Need To Slow Down
Oh shoot!
I looked up from the computer and glanced in my wife's direction. She was standing over a pot with the last drops of milk pouring out of the carton.
We're out of milk.
As straightforward as the statement sounded, I knew the alternate meaning. I would be running to the store shortly. I pouted pathetically.
Come on. You know they need to have chocolate milk before they go to bed.
If I left immediately, I could be home in time for dinner. I walked over to the mud room and struggled to get my shoes on quickly. When I looked up, two sets of small feet blocked my way to the door.
Can I come too?
They both spoke in unison as if they belonged to some sort of synchronized cult. In the blink of an eye, both kids were somehow decked out in boots and rain coats. I paused. My eyes moved from the clock to their quizzical faces.
Daddy is just running out for a moment. I will be right back.
Their smiles turned into frowns. My three year old daughter started to cry. I pushed my way out the door while they followed in tow. They stopped on the porch and waved as I opened the garage door. A sheet of rain separated me from their pitiful little figures.
*
While driving to the grocery store, I couldn't help thinking about the office. Today was the "go live" for our new electronic medical record. As expected, the stress in the air was palpable.
My patients stared glassy eyed as I fiddled with the computer. I repeated myself. I interrupted them. I was distracted. My agenda clearly wasn't their well being.
And strangely, it felt similar to what just happened with my kids.
I was going to the store for their benefit. But my children didn't really care about milk. They just wanted a ride with their father. If I listened to their opinion, I probably wouldn't be alone in the car at the moment. And that's how our patients must feel.
We're moving so fast with meaningful use, ACO's, and patient centered medical homes. We're punishing hospitals for re admissions and collecting "quality" data on our doctors.
We say that we are doing this for the "good" of our community. We talk about "patient centeredness" as if we own the term. But is anyone asking their opinion? Or are our patients left standing in the cold in raincoats and boots like little children?
*
When I arrived at the grocery store, I sprinted through the isles. I quickly grabbed two gallons of milk, and tapped my feet impatiently at the check out counter. I reached for the wallet in my back pocket, and was shocked at what I found. Or better yet, what I didn't find.
I left in such a hurry I forgot my wallet. It was the law of unintended consequences.
Has anyone explained to the government that you can't buy milk If you hastily forget your money?
I think we all need to slow down!
*
I left the store and drove back home. I picked up my wallet and kids, and we all went together on an adventure.
Our destination was the grocery store.
I looked up from the computer and glanced in my wife's direction. She was standing over a pot with the last drops of milk pouring out of the carton.
We're out of milk.
As straightforward as the statement sounded, I knew the alternate meaning. I would be running to the store shortly. I pouted pathetically.
Come on. You know they need to have chocolate milk before they go to bed.
If I left immediately, I could be home in time for dinner. I walked over to the mud room and struggled to get my shoes on quickly. When I looked up, two sets of small feet blocked my way to the door.
Can I come too?
They both spoke in unison as if they belonged to some sort of synchronized cult. In the blink of an eye, both kids were somehow decked out in boots and rain coats. I paused. My eyes moved from the clock to their quizzical faces.
Daddy is just running out for a moment. I will be right back.
Their smiles turned into frowns. My three year old daughter started to cry. I pushed my way out the door while they followed in tow. They stopped on the porch and waved as I opened the garage door. A sheet of rain separated me from their pitiful little figures.
*
While driving to the grocery store, I couldn't help thinking about the office. Today was the "go live" for our new electronic medical record. As expected, the stress in the air was palpable.
My patients stared glassy eyed as I fiddled with the computer. I repeated myself. I interrupted them. I was distracted. My agenda clearly wasn't their well being.
And strangely, it felt similar to what just happened with my kids.
I was going to the store for their benefit. But my children didn't really care about milk. They just wanted a ride with their father. If I listened to their opinion, I probably wouldn't be alone in the car at the moment. And that's how our patients must feel.
We're moving so fast with meaningful use, ACO's, and patient centered medical homes. We're punishing hospitals for re admissions and collecting "quality" data on our doctors.
We say that we are doing this for the "good" of our community. We talk about "patient centeredness" as if we own the term. But is anyone asking their opinion? Or are our patients left standing in the cold in raincoats and boots like little children?
*
When I arrived at the grocery store, I sprinted through the isles. I quickly grabbed two gallons of milk, and tapped my feet impatiently at the check out counter. I reached for the wallet in my back pocket, and was shocked at what I found. Or better yet, what I didn't find.
I left in such a hurry I forgot my wallet. It was the law of unintended consequences.
Has anyone explained to the government that you can't buy milk If you hastily forget your money?
I think we all need to slow down!
*
I left the store and drove back home. I picked up my wallet and kids, and we all went together on an adventure.
Our destination was the grocery store.
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