Guest guest Posted May 29, 2006 Report Share Posted May 29, 2006 In a message dated 5/2/06 12:01:56 AM Eastern Daylight Time, presentdayprods@... writes: > > Q: What Scares Doctors? A: Being the Patient > WHAT INSIDERS KNOW ABOUT OUR HEALTH-CARE SYSTEM THAT THE REST OF US NEED TO > LEARN > By NANCY GIBBS, AMANDA BOWER > > May 1, 2006, Time Magazine > > It's easy to imagine that doctors don't get sick. Surely the hygienic shield > of the sterile white coat guards them from ever having to put on the > flapping gown and flimsy bracelet, climb meekly into the crisp bed and be at > the mercy of the U.S. health-care system. And if somehow they did enter the > hospital as a patient, physicians ought to have every advantage: an > insider's knowledge, access to top specialists, built-in second opinions, no > waiting, no insane bureaucratic battles and no loss of identity or dignity > when you turn into the " bilateral mastectomy in Room 402. " But it doesn't > usually work that way. While doctors are often in a better position than > most of us to spot the hazards in the hospital and the holes in their care, > they can't necessarily fix them. They can't even avoid them when they become > patients themselves. When Dr. Friedman felt the lump in her breast in > the summer of 2001, she did--nothing. " I just sat on it, " she says, " because > I clicked into the mode of being physician, not patient, and I thought, > 'Most lumps are not cancer, I'll just watch this.' " That was her first > mistake. > > By September Friedman had watched long enough. An internist in a practice > that covers much of southern Wisconsin, she went to her radiology department > to schedule a mammogram. The administrators turned her down: her HMO paid > for routine mammograms every two years, and she'd had one 18 months before. > " I said, 'Wait a minute, I feel a lump. This is not routine.' They still > wouldn't let me do it. " > > This is the stuff bad movies are made of. Friedman had to appeal to the > HMO's board of directors. " I said, 'I'll pay for my own mammogram. Just let > me get it done.' " She won her appeal and finally had the test. " They didn't > even have to do a biopsy, " she says. " The radiologist just looked at it and > said, 'Oh, my God. You've got breast cancer.' " > > The education of Friedman, patient, had begun. Like any other > patient--and perhaps even more so--she had to drag information out of her > physicians. " They were treating me like I was knowledgeable, but they > weren't listening to me. " When she found out that the cancer had spread to > several places in one breast, Friedman told her surgeon there was no need to > preserve her breast for cosmetic reasons; she was more concerned that the > cancer be entirely removed. She asked for a mastectomy--but she was told > that a lumpectomy would do the job fine. " I went along with it, " she said. > That was her second mistake. Her breast was riddled with tumors. " They ended > up doing three lumpectomies. They were cutting away at my breast until I had > no breast left. I said, 'Will you please take it all off?' " > > Friedman's doctors weren't incompetent. They didn't operate on the wrong > breast or give her the wrong drugs or commit any egregious medical > errors--and that is the whole point. While there are bad doctors practicing > bad medicine who go undetected, that's not what scares other physicians the > most. Instead, they have watched the system become deformed over the years > by fear of litigation, by insurance costs, by rising competition, by > billowing bureaucracy and even by improvements in technology that introduce > new risks even as they reduce old ones. So doctors resist having tests done > if they aren't absolutely sure they are needed. They weigh the advantages of > teaching hospitals at which you're more likely to find the genius > diagnostician vs. community hospitals where you may be less likely to bring > home a nasty hospital-acquired infection. They avoid having elective surgery > in July, when the new doctors are just starting their internships in > teaching hospitals, but recognize that older, more experienced physicians > may not be up to date on the best standards of care. > > Most doctors freely admit that they do everything they can to work the > system. " As much as we all value fairness, if you think you can get some > special attention for someone who's important to you ... I don't know > anybody who would not play that card, " says McKee, vice chairman of > psychology and psychiatry at the Cleveland Clinic. But talk to doctors about > their experiences and you'll be surprised by how little power they have to > bend the system to their will. > > This is one abiding irony of progress. The most wondrous technology exists > that can pinpoint the exact location of a tumor, thread a tiny catheter up > into the brain to open a clogged artery, pulverize a kidney stone without > breaking the skin. But the simple stuff--like getting an MRI on time, being > given the right drugs at the right time, making sure everyone knows which > side of your brain to operate on--can cause the biggest problems. " A patient > with anything but the simplest needs is traversing a very complicated system > across many handoffs and locations and players, " says Dr. Berwick, a > pediatrician and president of the Institute for Healthcare Improvement. " And > as the machine gets more complicated, there are more ways it can break. " > > HOW TO GET THE RIGHT CARE > > Doctors are terrible patients because they know too much, " says Dr. Pamela > Gallin, director of pediatric ophthalmology at New York > Presbyterian-Columbia Medical Center and author of How to Survive Your > Doctor's Care. " They can't be both doctor and patient at the same time. " > They don't like appearing weak; they are schooled in a culture of stoicism > and sacrifice that cautions against complaint. In studies of the behavior of > doctors, most admit to writing their own prescriptions, self-diagnosing, > avoiding checkups. When they do have to enter a hospital as a patient, they > struggle with their role, scanning their bedside monitors and watching their > colleagues so closely that everyone can get a little spooked. " I don't like > the role reversal, " says McKee. " I suppose it's the way you feel when you're > 80 or 90 and your kids are taking care of you. It doesn't feel right. " > > But their innate resistance to treatment carries a message for the rest of > us as well. It requires almost a stroke of luck to enter a U.S. hospital and > receive precisely the right treatment--no more, and no less. A landmark Rand > Corp. study published in 2003 found that adults in the U.S. received, on > average, just 54.9% of recommended care for their conditions. Average blood > sugar was not measured regularly for 24% of diabetes patients. More than > half of all people with hypertension did not have their blood pressure under > control; one third of asthma patients eligible to get inhaled steroids did > not get them. > > Even more insidious is the danger of overtreatment. With well-insured > patients inclined toward hypervigilance, doctors afraid of missing something > and a reimbursement system that rewards testing over talking, there is > embedded in the system a dangerous impulse toward excess. Specialists are > typically paid much more to do a procedure than the family doctor who takes > the time to talk through the treatment options. A doctor who does a biopsy > may be paid as much as $1,600 for 15 minutes' work, notes Dr. Jerome > Groopman of Harvard Medical School. " If you're an internist, you can easily > spend an hour with a family where a member has been diagnosed with > Alzheimer's or breast cancer, and be paid $100. So there's this disconnect > between what's valued and reimbursement. " > > And yet sometimes, talking is the more important and certainly the safer > treatment. Ten more minutes spent taking a family history can reveal clues > that prevent a misdiagnosis or an unnecessary test; that childhood injury, > that illness during a trip abroad, that family history of excessive > bleeding. When the orthopedist hears that broke her leg when she was 2 > years old, he can hope that the dark spot on her tibia may not be a deadly > bone cancer but something more benign, like a Brodie's abscess. He may still > remove the abscess but not have to do a whole invasive tumor workup. Doctors > talk privately about the cost--economic and physical--of the bias toward > overtesting. They are less beguiled by flashy technology, more aware of the > risks of even simple procedures and thus more willing to trust their > doctor's instincts. If everything in his experience tells your doctor that > the lump on the back of your hand is a ganglion and not a malignant tumor, > it may not make sense to run the risk that goes with surgical excision. If > your baby is born after a very long labor but shows no sign of infection, > then agreeing to a spinal tap just to be sure may not always be worth the > risk. > > Doctors will argue privately that there is not enough watchful waiting and > re-examination anymore, partly because patience literally doesn't pay. " The > areas in the U.S. with the highest rates of use of hospital beds, > intensive-care units, specialist consultations and invasive testing don't > have the best quality of care and outcomes, " says Berwick. " In fact, they > often have the worst. It would be a great advance in both quality and cost > if somehow the American public came to understand that 'more care' is not by > any means always 'better care,' and that new technologies and hospital stays > can sometimes harm more than they help. " > > HOW TO FIND THE RIGHT DOCTOR > > You would think doctors have a great advantage in knowing whom to see for > their particular problem, and in one sense they do: they can tap into the > medical grapevine to find out who has the best reputation and the most > experience with a given procedure. They just have to hope that person isn't > their colleague down the hall. In a system that can seem infuriatingly > impersonal, a little distance is a valuable thing. > > Doctors will often choose not to be patients at their own hospital. There's > a risk that when treating a colleague, the physicians may lose their > objectivity and the patient his or her privacy. The same holds true for > anyone who goes to a doctor who is also a friend; you run the risk of losing > both. This is the hard fact that doctors know and patients have a hard time > believing: it's not just bad doctors who screw up. To an outsider, > everything that happens in a hospital has an air of magic, and the people in > the coats seem like wizards. But doctors know that physicians are people > too, who can get tired, or distracted, or simply one day fall a millimeter > short of perfection, sometimes with disastrous consequences. > > Dr. , a busy Southern California orthopedic surgeon, skidded > instantly from doctor to patient one day as he walked toward the operating > room, scrubbed hands raised, and slipped on a freshly mopped floor. He broke > the scaphoid bone in his right wrist, a bone that anchors all the bones in > the hand, especially vital for the physically demanding work of an > orthopedic surgeon. > > So he called on a friend who was a renowned hand specialist. " I knew the > procedure well, " he says. " Remove the scar tissue and place a tendon from my > own body to stabilize the other hand bones. " Naked under his hospital gown, > was rolled into the operating room cracking jokes with his doctor. > " I felt bad to be a bother, " he says. Together and his friend > decided to go with general anesthesia. An hour later, woke up and > said, laughing, " That was quick! " > > But his friend the surgeon was distraught. He had used a tool called a > rongeur to chew up the scar tissue and had accidentally chewed up the > scaphoid bone--ending 's ability to do orthopedic surgery. " The > actual damage happened in a matter of seconds, " he says. " I heard later that > he had told my wife while I was still under anesthesia. She said, 'You go > and fix it before he wakes up!' What she didn't know was that there are some > things that can't be fixed. " > > Although thinks his case was a " rare aberrant fluke, " that's not > exactly true. More than 1 in 3 doctors in a 2002 survey by the Harvard > School of Public Health reported errors in their own or a family member's > medical care. Dr. Wachter, chief of the medical service at the > University of California, San Francisco Medical Center, who co-wrote last > year's best seller Internal Bleeding: The Truth Behind America's Terrifying > Epidemic of Medical Mistakes, says he has seen it all: patients who had the > wrong leg amputated, were given the wrong (and deadly) medicines, had > surgical instruments left behind in the abdomen. Not all the errors are due > to ignorance or incompetence; even the best doctors can make mistakes. > > Imagine the dilemma of a physician trying to watch over a loved one when > things are going badly. Sherwin Nuland is a celebrity doctor; he was a > surgeon for 30 years, teaches surgery and gastroenterology at Yale and is > author of How We Die, which won a National Book Award. Last fall his > daughter, 21, faced a crisis. She had been born with hydrocephalus--fluid on > the brain. A shunt was put in, which worked fine for 21 years until it > closed down. " She needed a total of four operations to get this straightened > out, " Nuland says. The experience tested his self-control. " It helped that I > knew what [her doctors] were going through as these complications > occurred--how badly it was affecting them emotionally. Because she was the > daughter of a senior member of their faculty. " But in an emergency, emotion > is not an antidote for much of anything. However much we long for Marcus > Welby, it is less important to know and love your doctor than to trust and > respect him. And your prospects may benefit from his treating you with the > cool commitment of a professional rather than the comforting warmth of a > friend. > > HOW TO FIND THE RIGHT HOSPITAL > > Finding the right doctor is important: but so is choosing the right > hospital. There are all kinds of guides that can tell you what percentage of > heart-attack patients were prescribed beta blockers upon arrival or sell you > a report about your particular doctor. The problem is that it takes a > doctorate in statistics to sort out the data. " The world's best orthopedic > surgeon will be sent everyone's disaster cases, " says Wachter. " He may be > spectacular and still have worse outcomes than the crummy surgeon across the > street who has better outcomes because he gets the slam dunks. " Almost every > knee replacement results in few days of post-op fever. It's normal--but it > can still be cited in a report on the " high rate of postoperative > infection. " > > The most basic challenge facing every patient is knowing when to go to the > local community hospital and when to seek out the major teaching center. For > all their fame and all-star doctors, teaching hospitals carry risks of their > own. The sickest patients often have compromised immune systems and may need > to be treated with broad-spectrum antibiotics--which increases the chance > that antibiotic-resistant strains of staph and other bacteria will make the > rounds of the intensive-care unit. As a rule, doctors decide where to go > based on how sick they are. For fairly routine care--a hip replacement, a > hernia operation--they will often opt for the convenience and comfort of a > community hospital. But if there is any mystery about the symptoms, the rule > is Get Thee to a Teaching Hospital. The meals will probably be worse, the > beds may not get made on time, a spirit of competent chaos may abide; but > for complicated surgeries, the mortality rate is typically lower because the > volume of cases is higher and the surgeons are more experienced. Plus, the > presence of all those interns and residents has a way of keeping doctors on > their toes. > > There is, however, at least one exception to the rule. > > HOW TO SURVIVE JULY > > Harvard's Groopman, who has written three books about the doctor-patient > relationship, lived through his own doctor-patient nightmare. It started > when his son had a medical emergency in July, which every doctor knows is > the worst of all months to go to a teaching hospital. " The new interns and > residents begin July 1, " he explains. " There's a very morbid joke: don't get > sick on the July 4 weekend. " But years ago, when he and his wife were new > parents, they were visiting her family in Connecticut for the holiday when > their 9-month-old son became cranky, ran a fever, got diarrhea. They went to > a local pediatrician, who essentially said, 'Oh, it's nothing: you're just > neurotic doctor-parents. Give him some Tylenol.' " > > By the time they arrived back in Boston, it was clear to both of them that > the baby was very sick. " He was flailing and arching his knees to his chest. > So we rushed to the emergency room of the Children's Hospital. " Their son > was seen by a brand-new surgical resident, who diagnosed an intestinal > obstruction. " This resident said to my wife--this is now midnight--'Well, in > my experience, this can wait until morning.' " Since his experience at that > point in his residency amounted to roughly three days on the job, the > Groopmans pulled rank. They called someone who called someone who happened > to be home on the holiday, and they wound up with a senior surgeon who came > in, did an emergency operation at 3 a.m. and, Groopman says, saved his son's > life. > > That was an extreme lesson in the value of experience; no one recommends > seeking out doctors who are brand new on the job, and doctors admit to > scheduling elective surgery--even planning childbirth--around the intern > calendar. This is not paranoia: the average major teaching hospital > typically sees a 4% jump in its risk-adjusted mortality rate in the summer, > according to the National Bureau of Economic Research. But there is a larger > issue that doctors argue about: which matters more, information or > experience? Broadly speaking, a younger doctor is likely to have been > trained in the newest surgical procedures, be more up to date on the > literature, and be more open to new techniques. Older doctors have had more > years to develop the instinctive diagnostic skills that can make the > difference in complicated cases and may be skeptical of innovations that are > driven more by marketing than medicine. > > Older doctors are also worried that rules designed to make young doctors' > lives easier may make patients' outcomes worse. Back in the day, grizzled > veterans say, a medical resident was called that for a reason: he--and they > were all men--actually lived in the hospital. " We were aggressive about our > training, " recalls a former surgical resident at Boston's Brigham and > Women's Hospital. " The only thing wrong with every other night call was that > you missed half the good cases. " But these long hours of dedication came at > a cost: tired doctors made mistakes. Studies showed that long work hours > increased stress, depression, pregnancy-related complications, car wrecks > and damage to residents' morale and personal life. So now residents' hours > are limited to 80-hr. workweeks averaged over a month, in shifts that are > limited to 24 hours of patient care, with at least 1 day off in 7. Remaining > on call in the hospital is limited to every third night. Hospitals that fail > to comply can lose their accreditation. > > The reforms made intuitive sense; but the unintended result, older doctors > warn, is a 9-to-5 mentality that detaches the doctor from the patient. They > fear that young doctors don't get the experience they need or build the > instincts and muscle memory from performing procedures so many times that > they can do them in their sleep. Even the residents may agree: in a 2006 > study in the American Journal of Medicine, both residents and attending > physicians reported that they thought the risk of bad things happening > because of fragmentation of care was greater than the risk from fatigue due > to excess work hours. Other residents say that while they may feel more > rested, they sense that they are not learning as much or as fast as they > need to. > > " I know that I will not like it 20 years from now when I'm 68 and having to > be taken care of by these guys, " says Dr. Shekelle, a professor of > medicine at UCLA. " It's all shift work now. When 5 o'clock comes, whatever > it is they're doing, they just sign it all out to the 5 o'clock person. It's > eroding the sense of duty, or commitment to being the person responsible for > a patient's care. " > > But younger physicians may have other advantages--like a fresher sense of > the latest standards of care. Many doctors have concluded that there is > something of a sweet spot on the age-education-experience continuum. They > seek out clinicians who are no more than 10 years out of residency, old > enough to have some mileage, young enough to be up to speed. There is > actually some hard data for this rule. A review published last year in the > ls of Internal Medicine examined the connection between a doctor's years > in practice and the quality of care he or she provided. To the surprise of > everyone--including the review's author, Harvard Medical School's Dr. > Niteesh Choudhry--more than half the studies found decreasing performance > with increasing years in practice for all outcomes assessed; only 4% found > increasing performance with increasing age for some or all outcomes. One > study found that for heart-attack patients, mortality increased 0.5% for > every year the physician had been out of medical school. > > HOW TO SURVIVE TECHNOLOGY > > We think of hospitals as cathedrals of science, yet doctors walk around with > their pockets stuffed with 3-by-5 cards on which they write patient > information; when they sign off for the day they read from the card to the > doctor coming on duty. " My pizza parlor is more thoroughly computerized than > most of health care, " says Berwick. It's easy to see the advantage of giving > everyone easy access to a patient's history and test results. But getting > there can be painful. Enter a hospital when it is in the process of > introducing more computers, they say, and you can hear the sound of nurses > growling. Doctors using laptops sometimes have to wrestle with incompatible > systems, manually retyping lab results from one computer into another. > > The introduction of computerized patient information and medication orders > is meant to reduce " adverse drug events " and ensure that the patient's > history and treatment notes are available to everyone who needs them. But > progress does not always equal safety. " Technology should remove the burden, > but you can get problems. You can hide behind technology and spend more time > talking to your computer than to your patients, " says Dr. Albert Wu, a > professor of medicine at s Hopkins. " And as with any new thing, people > screw things up worse before they make things better. " Doctors say there is > a temptation to trust computers too much: they seem objective and > infallible, but if the wrong information is entered in the first place, or > the bar-coded wristband is put on the wrong patient, it can be harder to > prevent mistakes down the line. In one case study, a patient with pneumonia > had his wristband mixed up with a diabetic patient and came very close to > being given a fatal dose of insulin. > > This is why doctors are reluctant to be hands-off when it comes to a loved > one's care. Until proper safeguards are built into the system, what a > patient needs most, many doctors agree, is a sentinel--someone to take > notice, be an advocate, ask questions. Now that the family doctor has been > squeezed out of that role, someone else has to step in. But even a > doctor--family member may not be able to counter the complexity of the > system. Dr. Berwick of the Institute for Healthcare Improvement tells the > story of his wife Ann's experience when she developed symptoms of a rare > spinal-cord problem at a leading hospital. His concern was not just how she > was treated; it was that so little of what happened to her was unusual. > Despite his best efforts, tests were repeated unnecessarily, data were > misread, information was misplaced. Things weren't just slipping through the > cracks: the cracks were so big, there was no solid ground. > > An attending neurologist said one drug should be started immediately, that > " time is of the essence. " That was on a Thursday morning at 10 a.m. The > first dose was given 60 hours later, on Saturday night at 10 p.m. " Nothing I > could do, nothing I did, nothing I could think of made any difference, " > Berwick said in a speech to colleagues. " It nearly drove me mad. " One > medication was discontinued by a physician's order on the first day of > admission and yet was brought by a nurse every single evening for 14 days > straight. " No day passed--not one--without a medication error, " Berwick > remembers. " Most weren't serious, but they scared us. " Drugs that failed to > help during one hospital admission were presented as a fresh, hopeful idea > the next time. If that could happen to a doctor's wife in a top hospital, he > says, " I wonder more than ever what the average must be like. The errors > were not rare. They were the norm. " > > After he publicized his experiences, Berwick was besieged by other doctors > saying, " If you think that's terrifying, wait until you hear my story. " One > distinguished professor of medicine whose wife was hospitalized in a great > university hospital was too frightened to leave her bedside. " I felt that if > I was not there, something awful would happen to her, " he told Berwick. " I > needed to defend her from the care. " > > It's hard to find a doctor who doesn't worry about how medicine is changing, > since they suffer at both ends: as providers of health care and as > consumers. " What scares me most about the current medical environment is > complacency with the status quo, " says Palmeri, an internal medicine > resident at Dartmouth-Hitchcock Medical Center in New Hampshire. Burgeoning > bureaucracies, managed care, the mass production of health-care services and > a worsening malpractice climate only strain the doctor-patient relationship. > In this environment, the patient, typically a physician's source of > inspiration, can become the source of frustration. " When I refer one of my > family members to someone, " Palmeri says, " I want to make sure that they are > the type of physician who leaves no stone unturned and will burn the > midnight oil if need be to ensure the highest-quality care possible. " > > What frightens doctors--young ones like Palmeri as well as older ones--is > that those doctors may be harder and harder to find. Scientific knowledge > improves, but the care doesn't keep up; it is easier to gather gigabytes of > information than to acquire the judgment to apply it wisely. It might > comfort the rest of us to think that with just a little more knowledge or a > personal doctor at our side, we could get the best out of America's > extraordinary health-care system without suffering from its gaps and > failures. But since even an insider can suffer, we are left with the much > harder challenge: to fix the system for everyone. > > -With reporting by With reporting by Coco Masters/ New York > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.