Hiatus

Well, it's been a while since my last post. I have every intention of starting up again, but first let me explain why:



My daughter, Cecilia Jang Lubetsky, was born on May 21st, 2009. Having her and raising her is the hardest thing I've ever done (and am doing), including med school, my PhD, internship, everything. She's also the most rewarding thing I've ever done (and am doing) and I would not change a thing.

Doctors as patients, part 1

It has often been said that the doctor's working in the hospital are the unhealthiest people within the whole hospital. I think I already made a reference to this in a previous post about doctors exercising. I think I can expand this thought and say that in general, doctors are horrible about taking care of their own health and make horrible patients.

I'm reminded of something that happened while I was in med school - one of the most respected surgeons at my hospital suddenly was diagnosed with lung cancer. He never smoked, it was just bad luck. He had been ignoring his symptoms for years and years, and even though he went through surgery and chemotherapy and his colleagues did everything possible to save him, he was dead within something like 4 months, which is very short, even for lung cancer.

I think there are a few reasons why doctors take such bad care of their own health. One is simply a time factor. When you work 80 hours a week, even if you only work 60 hours a week, it's hard to find time to go to a doctor or dentist appointment. Often, even the time you have off from work is spent catching up on the latest medical news or journal articles, which is necessary to stay current. Moreover, since most doctors have daytime working hours, it's nearly impossible to take time off during the day to make it to an appointment - you have to either cancel your own appointments, or arrange for coverage, both of which are costly, time-consuming and extremely inconvenient for you, your patients, and your colleagues.

Secondly, I think it's the medical culture. Even when doctors are deathly ill, they try to come into work unless it's a risk for their patients. This is partly because calling in sick means that you have to inconvenience your colleagues and your patients, and since doctors don't really get sick days, you have to make up the work at some later date, usually on a day off. Additionally, doctors like to be tough, and seem tough, and illness, even for doctors, is a sign of weakness. As a result, many doctors become trained to ignore their own symptoms, even when they are persistent or become serious.

Finally, many doctors feel that they can treat and diagnose themselves, and don't need to go in for an appointment, even though this is often not the case. By treating themselves, doctors again often ignore or miss important symptoms and miss out on getting valuable input or a second opinion from a colleague. Doctors tend to treat themselves very differently from their patients.

In the end, my point is that doctors need to take care of themselves as they tell their patients to do so. They need to go for their yearly checkups, screening tests, etc and not try to manage it all on their own, for their own sakes as well as to be good role models for their patients.

In a very different way, doctors can be bad patients even when they do seek medical advice... I think I'll leave that for another post...

Doctor Shortage

People have been reporting about this for quite a while, but a friend just recently forwarded me this NY Times article about how there will be a severe shortage in doctors in the future, especially in the primary care field. It seems many people, including the current Obama administration are becoming increasingly worried about this problem. While some steps are being taken to try and delay this crisis, there are many many roadblocks.

Of the ideas that have been proposed or already instituted to try and solve this problem, one includes increasing the sizes and numbers of medical schools. Medical schools may have to admit more students that don't have science backgrounds - while some worry that this may decrease the quality of medical students and eventual doctors, I don't think this is a problem and may even be of benefit. Medical schools already admit plenty of students with non-scientific backgrounds and as long as they can build up a significant fund of knowledge either in medical school or in a year of study before entering, I think it's not a problem. In fact, it may even build diversity and bring new ideas and perspectives to the table, which is definitely a good thing.

Another idea is to increase the use of non-MD sources of health care, including nurses and other health care professionals, which I think is a great idea. However, there is also a nation-wide shortage of nurses, so this avenue may be limited as well. Finally, it has been suggested that we use more minority as well as international doctors as there are many MDs from other countries who would like to practice in the U.S. Obviously this presents many problems as training in other countries can be vastly different than training in the U.S. and currently, depending on the country they come from, international doctors often have to retake licensing exams, as well as complete full residencies (after having already completed residencies or full training programs in another country) in the U.S. This is a huge deterrent for MDs coming from other countries to try and become MDs in the U.S. - I don't know how many international MDs I know who have instead become lab technicians or Ph.D. students or post doctoral students because the requirements for them to practice medicine in the U.S. are so overwhelming. However, I don't have a great solution for this as I do believe the training is different from country to country and that international MDs should practice in the custom of U.S. training, for legal purposes as well as medical.

Despite these efforts, I see a lot of hurdles for which there are no easy answers or solutions. One is that even though medical schools may be increasing their enrollment, there are a limited number of residency training spots available. These are being increased as well, but they cannot be increased as easily or at the same rate as medical school spots. Residencies are much more complex to set up, and must go through a thorough accreditation process every couple of years, which is not only cumbersome, but can be difficult to arrange and maintain.

Moreover, there is heavy competition for competent people by other professions, the major competitors being business and law. Now, with the economy being the way it is, business has been less attractive the last few years, and perhaps the medical pathway is getting a boost from the decrease in business school applicants or business jobs. However, law and business careers can be much more attractive than medical careers - the training is much shorter. School takes half as long, and after school you start earning a relatively good salary right away whereas in medical school, it can take 4-6 years, with 3-5 year of low-paying residency afterwards, sometimes followed by 1-2 years of low-paying fellowship. Once you finally get out of all this training, doctors (especially primary care) often still make lower salaries than lawyers and businessmen, and have to contend with other headaches and costs associated with malpractice insurance, insurance paperwork and red tape, etc. Until there is good health care reform, or salaries become more equalized (either doctors' salaries have to come up or other salaries should be lowered - probably the latter is better for various reasons), there's not much that can be done about this problem.

Finally, even with the increase in medical school admissions and residency spots, many people are still attracted to practicing in medical specialties rather than primary care, in which the doctor shortage is the most severe. Again, this likely is due to a salary differential as primary care doctors make much less than doctors in medical specialties. As with competition with business and law degress, not much can be done about this problem until the salaries equalize - in this case, I think primary care doctors should be valued more highly and their salaries increased.

Bruce's Asia Travels Blog

Bruce (my brother) is traveling in southeast Asia for about 2 months, and he'll be keeping a blog about it. I'm so jealous. :)

Sympathy vs. Empathy

I remember in medical school being taught the difference between sympathy and empathy - a lot of people tend to use them as synonyms. In my line of work, when you empathize with someone, it means that you can feel what they are feeling. For example, if they have some type of cancer, and you've had that exact type of cancer, you can feel something similar to what they must be going through and you "empathize." If you feel sympathy for someone, then it's more that you understand, or try to understand as best you can, what the person is going through but you may not feel or have not felt that way yourself. In my opinion, it's very difficult to empathize with someone unless you've gone through a very similar process or situation that they're going through.

Having said all this, I highly empathize right now with all the 9 month pregnant ladies out there who like to deliver soon. :)

Doctors in training

A family member sent this article to me, and there's a link within the article to another related column.

They basically talk about the culture of negative reinforcement for medical interns and residents. It's fairly common for residents to get yelled at or chewed out by attending doctors for various things in the hospital. Moreover, these episodes can often be about relatively unimportant things, or things that are in no way the fault of the intern or resident, and the attending if often venting their anger and frustration on those that are beneath them. As the article points out, I think most people can agree that such public displays of anger and criticism are not useful or constructive in any way. As the second article explains, positive reinforcement and constructive criticism is much more useful. However, this doesn't stop certain attendings from taking out their anger on their subordinates, which clearly isn't right and can often drive interns and residents out of the medical field altogether.

Being an intern, I've definitely seen plenty of things like this first-hand, although thankfully I've very rarely been on the receiving side. I think the best way to deal with people like this is to simply provide the best medical care you can, and, to be perfectly honest, ignore the attending for the time being! Obviously, if something should have been done differently, either medically or otherwise, you take that lesson with you, but if someone is yelling at you unnecessarily and unhelpfully, you would probably make the situation worse if you speak up about it at that time. It can be a very difficult position as the attending has a lot more power and influence than you and it can be very intimidating. If you feel very strongly about it, there are usually avenues you can follow (such as taking the issue to a program director or an ombudsman) to address it later. I think the best lesson to learn from an episode like that is how you do not want to be an attending like that in the future, knowing how it made you feel as an intern or resident. I think also, that interns and residents should have a thick skin and be prepared to shrug things like that off as long as the abuse was truly unwarranted.

For what it's worth, I think certain specialties are more prone to this type of abuse by attendings, and I also think the incidence is declining as programs and doctors become more aware of it and interns and residents are more outspoken about it.

Mira Loma High School and the Science Bowl

I just have to post something unrelated. I went to Mira Loma High School, and (shockingly) I was pretty nerdy - I competed in all the science and math competitions, including Mathletes, Science Olympiad, Science Bowl, etc. There were a few others that I can't remember off the top of my head right now, but our crowning achievement was winning third place in the National Science Bowl competition under our chemistry teacher, Mr. Torgeson, wayyyy back in 1994. This won us a week-long all-expenses-paid trip to Hawaii. Needless to say, for a bunch of high school students, we were ecstatic!

Well, it seems we've been outdone, as this year's team took first place, getting them a trip to Australia! See the link below for the article in the Sacramento Bee:

http://sacbee.com/topstories/story/1833334.html

Congrats!! I'm glad to see the legacy continuing.

Keeping fit as an intern

It's impossible. Especially now that I'm pregnant. But even when I was really busy before, I still was able to get some exercise in, sometimes at the gym, and sometimes playing ultimate frisbee, which has basically been my most enjoyable form of exercise for the last 6-7 years. It's well-known that interns often gain 10-15 pounds during their intern year, and in general eat a lot unhealthier and get a lot less exercise. They say (jokingly) that the doctors are often the least healthy people in the hospital... obviously it's important to stay healthy, for their own sakes as well as to set a good example for their patients, but it can be extremely difficult.

I think the best way to combat it is to try and get into something active you really enjoy - for me, that's ultimate frisbee. To be honest, this post is really just a plug for my sport. :) I guess since I'm a woman, and play ultimate frisbee (not to mention captained a women's club team and multiple league teams in the past), many people have forwarded this New York Times article to me. It's mostly about women and ultimate frisbee, and I think it's great that the sport is finally getting mainstream attention.

Kaiser and their electronic system

This is an interesting article about how Kaiser instituted their electronic medical record system.

I had written a previous post about this subject and still think it's a great idea, although possibly prohibitively expensive. However, one argument is that electronic records could eventually lead to cost -savings- as medical tests and studies are not unnecessarily repeated. Interestingly enough, the article says that the costs savings aren't really there as people are living longer with better care, and thus require more health care resources in the end, which off-set the potential savings in medical costs. Nevertheless, the article does point out that shared electronic medical records lead to better care and for that reason, it's still worth it to attempt implementation of these systems in all hospitals. Hopefully they will all eventually even be compatible with each other, if not already part of a common universal electronic medical record keeping system.

Doctoring Online

This is a very interesting concept. It's a service that allows you to mostly connect with your doctor online through video chat, IM, and email after an initial face-to-face office visit. I think it's a great idea for simple problems that people have that can be diagnosed over the phone or email. I think it breaks apart when a patient comes in with more complex problems or health issues, making a good physical exam necessary. Then you need an actual doctor's appointment, just like with any other private practice.

Perspective on Costs

I hear arguments or complaints all the time about how we're denying so many people health care because "an insurance company won't pay for it" or "it's too expensive for them to cover it". For example, many times, patients and their families (and their doctors) will fight with insurance companies to get them a really expensive treatment or get an exception to get a certain patient a treatment that usually the insurance company would not approve, either because it's too expensive or isn't indicated. While I'm the last one to support the insurance companies and I think they could be doing a lot more to cut costs and provide more and better health care, I think that many people are lacking perspective about this topic.

I don't think anyone would disagree with the statement that the budget for healthcare is limited. We can't spend all the money we want to save everyone in the world. In the US I think this is often not understood well because we have a relatively wealthy country, but it 3rd world countries, like many in Africa, or in countries that have 3rd world elements (like India or China), this is readily apparent.

When someone or a group of patients can't get a treatment because it's too expensive, many people react with indignance and outrage. While I certainly understand this sentiment, and probably would feel it myself if I or one of my family were the patient, there's another side to the story... By providing that one patient (or group of patients) with that expensive treatment, you are essentially denying health care to another group of patients. Just take for example that a treatment costs $100,000 per patient to save their life. Of course you can't put a $ value on a life, but say that $100,000 could be spent on 100 other people to treat something else to save their lives. Or maybe to, say, treat their hypertension and prolong their lives for 20 years each. It's hard to say which is the right way to go, but personally, I think it should be spent for the greater good.

Personality

Personality plays a large role in many different careers - it's no difference in the medical world. If you have a good personality, patients often like you better and think you're a better doctor. Similarly, if other medical colleagues get along with you well, they usually think more highly of you as a clinician. This all leads to more referrals, by patients and doctors alike. I think personality is supremely important in a doctor, and certainly is part of being a good doctor - you don't want a clinician who is callous or unfeeling, or someone who does not deliver bad news well.

However, personality is not everything. I think many good clinicians often lack in the personality area, or at least the empathy/sympathy area simply because they are too busy. And unfortunately, many times patients will label them as bad doctors because they don't like their attitude or the way they present themselves. I think that's totally valid, but I also think sometimes patients may be losing out on very good care because they may be too demanding and not understanding enough of their doctors.

I think it's even worse when other medical professionals assume that someone is a good doctor just because they get along with them well, or that person has a good personality. I've met plenty of people who I like to hang out with, but who I don't necessarily thing are the best clinicians. I don't necessarily think they're horrible, or even bad, but some people think they're great because they are really easy and fun to get along with, and I just think they're ok clinicians. I think that first and foremost, a doctor has to be a good clinician (making good clinical decisions, etc) and then secondly, should be empathetic and have good relationships with his patients. If the doctor can do both well, then that's great, but the first characteristic is the most important.

Being a health care professional in bad economic times

One good thing (of many, I think) of being a doctor during bad economic times - you pretty much are guaranteed a job. Especially in this day and age, with more and more people living longer and longer, people will always need doctors and nurses, and other health care professionals. In fact, there's an increasing demand for them. I'm sure salaries may go down, and people may have to work (even) longer hours and care for more patients in a shorter amount of time, but at least they're usually not at danger for losing their jobs. At the worst, people may have to relocate or take less-than-ideal jobs or situations in order to keep their incomes flowing in.

It's a reassuring thought this year considering 2,000,000 people have lost their jobs so far in the U.S.

Hospital Closings

There are all these rumors flying around that Methodist Hospital in South Philly is closing. This is in addition to Northeastern Hospital in NE Philadelphia already closing! If Methodist Hospital closes, that will really put other hospitals in a difficult position. If the other city hospitals are anything like Pennsylvania Hospital, they're already overfilled with patients currently. How are they going to handle the load and stress of another hospital closing? It's a very sad state of affairs when hospitals have to close because they're losing money.

Abusive, Arrogant Doctors

This is an interesting article. It talks about how arrogant and abusive doctors can (not surprisingly) really affect the health care of a patient, not to mention affect the workplace and those around them. I've definitely run into plenty of them myself and experienced it firsthand, not to mention heard of other abuses plenty of times. It's a very unfortunate and inappropriate problem. As the article points out, I think the good thing is that there is awareness of the problem and steps are being taken at every hospital to minimize and eliminate it. Interestingly, many of these doctors happen to be surgeons - go figure.

I just also wanted to mention that I've been on the receiving end of this from not just doctors but also nurses, physicians' assistants, nurse practitioners, you name it. So although I will agree that it's much more prevalent in doctors than other medical staff, it is definitely not phenomena limited to MDs alone.

Difficult Decisions

Sometimes people have so many different diseases that it's difficult to decide which one to treat. For example, one common conflict is between the heart and the kidney. If you have too much fluid in your blood vessels, and if your heart is weak already from other processes, that can make your heart even weaker and it can't pump all that fluid around. As a result, the fluid can build up in your legs and arms, and in your lungs, making you short of breath. The treatment for that is to "diurese" a patient - that is, use medications to make people urinate and decrease the amount of fluid in their veins. However, if your kidneys are sick, you need a higher dose of these medications, which can actually harm your kidneys even more. However, the higher doses may be a necessity to keep your heart healthy. It is not uncommon for there to be a natural conflict between the cardiologists (heart doctors) and the nephrologists (kidney doctors) over this very situation. In the end, often the cardiologists win out because while we can treat kidney failure (at least temporarily) with dialysis, if your heart fails, we don't have any sort of substitute for that.

There are many such decisions that clinicians often have to make. I tend to think that usually things work out ok - if we see signs that we made the wrong decision, we can always change and go the other way the next day. Unfortunately, some people are on such a fine balance that choosing the wrong path for even a few hours can sometimes be hugely detrimental. Hopefully through collaboration and talking together with many specialists, we can make the right decision the majority of the time.

Little Fish

We just went to Little Fish for dinner tonight. It was excellent - enough so that I have to blog about it. :D

For appetizers, we had diver scallops with orange, almond and serrano ham as well as peekey toe crab with red beet, tarragon butter and shaved fennel. The crab was very flaky with an excellent texture - a little plain, but still good. However, the diver scallops were excellent - cooked to perfection with a wonderful flavor, and surprisingly good with the almonds and mandarin orange slices.

For entrees, I had the skate (a type of ray) with truffled spaetzle and shredded leeks. I think this is their most praised entree. This was absolutely amazing! The skate was fried lightly so that it was crispy on the outside but very soft and moist on the outside. The sauce was a salty parmesan broth that complemented it very well. The leeks were also tasty and complemented the strong-tasting fish very well. Pete had mahi mahi with a sweet potato puree which I believe was also very good, but not nearly as good as the skate. I would go back to eat skate at this restaurant any time.

Transfer of Care

At almost all hospitals, interns and residents go through rotations that last about 4 weeks at a time. That means at the end of the four weeks, you transfer care to another team. Like I mentioned in the previous post, at Pennsylvania Hospital, we use a night float system. So what happens at the end of a rotation, one team signs out to night float with a paper signout describing all their patients (like a normal night) and the next morning, the new team picks up the paper signout with news about whatever happened overnight from the night float person. As the night float intern takes care of about 100 patients (or more) a night, they don't know any of these patients in detail unless they're pretty sick, so they don't really have any details to hand off to the new team in the morning. There is really no verbal communication between the new intern and the old intern regarding the patients. The best continuity comes from the resident of the team, who is on for about 4 days before the interns switch, so they know the patients at least to some small degree, although they often do not know the small details, or the really complex patients well.

As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.

However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.

Night Coverage

Clearly, doctors can't be at the hospital 24 hours a day, 7 days a week, so for at least some of the time, their patients have to be cared for by somebody else. Different hospitals handle this in different ways. At Pennsylvania Hospital, there is a night float system. Most of the interns leave the hospital at night and sign their patients out to a single night float intern who works from about 5pm to 7am. The good thing is that most interns actually get to leave the hospital at night and are refreshed the next day to do work. The bad thing is that the night float intern is taking care of probably about 80-100 patients a night, and since you get signout on so many patients, it's not that detailed and you really only remember the really sick patients or make a note of specific things you have to do for certain patients. That means that night float doesn't know most of the patients very well at all - they just handle critical issues at night. Most patients are sleeping at night, and there's not much going on, so it's manageable, but if there are quite a few sick patients that night, it can get very busy and complicated. The good thing is that there is a resident or two for backup if things do get ridiculously busy.

Some other hospitals do it differently. They have teams that round together, and at night, 3 interns will sign out to one other intern for the night. The good thing is that that since they all round together, that intern staying overnight is supposed to know all the patients relatively well. The bad thing is that one out of every 4th intern stays overnight, making 25% of the interns extremely tired and miserable the next day (since usually they get very little to no sleep) and also decreasing the work force by 25% the next day since they have to leave by noon.

It's hard to say which is the better option. It's bad to have so many interns tired working the next day as studies show that the more tired doctors are, the more mistakes can be made (not that they are common by any means). This is an argument for the first system, like at Pennsylvania Hospital. However, newer studies are starting to show that the more times care is transferred between different doctors, especially doctors who are not super familiar with the patients to begin with, the more mistakes can be made (again, not that they are common). This would be an argument for the second system.

In fact, there are rumors of new legislation in the works that forces interns to take a nap (!) in the middle of call for at least 3-4 hours. During this time, they would have to somehow sign off their patients to someone else, and then get them back at the end of their nap. This is all part of ongoing legislation reform about duty work hours (a whole other post). However, the problems with transfer of care may be an argument against doing this sort of thing. Until hospitals have more money to hire more helpers (e.g. RN's, NP's, etc) that can at least do part of the work of interns, I guess we'll have to make do.

Proper Use of the Emergency Room

I had a patient the other day who came in to the emergency room (the ED) at the suggestion of his primary care doctor. He had extremely high blood pressure at his doctor's office, but by the time he came into the ED, he had taken the blood pressure meds he was supposed to take, and his blood pressure had dropped significantly - almost normal! In addition, even though he had extremely high blood pressure, he never had any symptoms from it, and so although we might take steps to lower it in the ED, we likely would not admit him, especially now that his blood pressure had come down to almost normal after taking his blood pressure medications, which is how it should be.

The patient was livid. He had paid his $50 to get evaluated in the emergency room and demanded that he be admitted. He claimed his doctor had promised him an admission, which was not true, as we talked to that doctor ourselves.

Although not great, I use this as an example of how people misuse the ED and have the wrong preconceptions about it. Some people I understand - they don't have insurance, so they basically use the ED as their primary care. I don't like it, and I think there are better ways to deal with this or solve this problem (a whole topic in itself), but I understand. What I don't understand is why some people come into the ED at all when they have good primary care or have non-urgent problems.

The Emergency Room is supposed to be for EMERGENCIES. It is for people who can barely breath from pneumonia, not for people suffering from run-of-the-mill colds. It is for people who have broken bones and fractures, not for people who have had lower back pain for the last 6 months. It is for people who are vomiting so much or have so much diarrhea that they are seriously dehydrated, not for people who may have one episode of vomiting or diarrhea but are still able to eat and drink just fine. It is for people who are having a heart attack, not for people who have had "chest pain" that has been proven to be not related to their heart for the 10th time.

Not only is it a huge waste of public and hospital funds, but I don't understand why people would want to spend hours and hours in the uncomfortable waiting room of an emergency room when they can make an appointment with their primary care provider. In fact, when it gets super super busy, and people stay outside in the waiting room for hours and hours waiting to get seen, you can actually see people start to leave. In my opinion, if they weren't sick enough to stay and wait, they shouldn't have been there in the first place.

When things don't go as planned...

Several months ago, I met a patient who had already been in and out of the hospital for months. He already had had many complications and was pretty sick. This guy had bladder cancer and had to have his bladder taken out. His ureters - the tubes that carry urine from your kidneys to your bladder - were instead fused to a part of his colon so that urine was diverted to his colon instead of his bladder. Immediately after the surgery, he had a heart attack, which is not common, but can happen because surgery takes such a big toll on your body, including your heart. He recovered well from this, and went home. Unfortunately, two days later he came back to the emergency room looking incredibly sick. It turns out that his wound had started to come apart, which is a potential complication of any surgery. His ureters were de-attaching from his colon, leaking urine into his abdomen, and he possibly had an infection within his abdomen. They had to open him back up and fix everything. In the end, it was all still leaking, so they had to place stents within his kidneys that led outside his body to drain the urine instead. He was discharged to rehab.

One week later, he was having his stents changed, and he suddenly became very very sick - he had a fever, the chills, and looked really sick. That's when I saw him. He had developed a very serious infection called sepsis where the infection is basically all throughout your blood. His blood pressure started becoming way too low and he had to eventually be transferred to the ICU where they could start him on special medications to keep your blood pressure up and your heart pumping. It turned out he had multiple types of bacteria growing in his urine, as well as fungus growing in his blood! That's pretty rare, but he had many potential sources of infection - not only did he have the normal sources that every else has (lungs that can develop pneumonia, urine that can develop urinary tract infections, and blood that with even just a blood draw can potentially develop bacteremia or sepsis), he had stents in his kidneys as well as an ostomy (his colon came to his skin and his stool came out through a bag) that were at high risk for infection. Moreover, he was a pretty sick guy, and he'd been in the hospital quite a lot over the last few months, so he was immunocompromised and at higher risk for infections, including hospital-acquired infections. Eventually, he was discharged about two weeks later to yet another rehab facility after being treated with multiple antibiotics.

Two weeks later he came back again. Actually, he had two emergency room visits in between as well. This time, he had developed serious bleeding from his gastrointestinal tract, requiring many blood and platelet transfusions. Over the next 6 weeks, he developed sepsis again and multiple infections, and also developed respiratory failure requiring intubation to help him breathe. Although after several weeks we were able to take the tube out and he could breathe on his own, he was still incredibly sick and his prognosis was very very poor. After many discussions and having dealt with this for nearly 6 months, his wife decided to make him DNR. After 6 more weeks in the hospital and the ICU, he eventually died.

I tell this story because sometimes, it can be amazing what a relatively simple procedure can lead to. I would not call a bladder removal a simple procedure, but I'm pretty sure this patient and his wife went into the operation with an optimistic attitude. He had bladder cancer, but it would be removed, and he would have to pee in a bag for the rest of his life. Traumatic, perhaps, but something you could live with. Instead, he had 6 months of increasing medical complications that eventually led to his death. I don't think the doctors did anything wrong at all, or could have done anything differently - sometimes it's just bad luck and unfortunately, patients and their families are often not prepared for things like this.

Smallwood

From Smallwood Feb 7, 2009

That was a fun weekend.

A Universal Electronic Medical Record System

I have an ongoing discussion with my husband about this - the need for a universal electronic medical record system. I don't think anyone really disputes the benefit we would have from such a system. The only thing I could think of is that it may be easier to access the system and there may be more breaches of individual privacy.

The potential benefits are enormous. I can't count the number of times patients come into the hospital or the emergency room with inadequate histories of their own medical care, or without a list of their medications. With a universal electronic system, there would be improved continuity of care, resulting (hopefully) in improved medical care. Not only would we have all their lab and imaging results at our fingertips, but we could get in touch with all the primary care doctors and specialists much more easily for additional information. This can be especially difficult to do if you are trying to contact a doctor at a different hospital or clinic after hours. Secondly, there would be a huge savings in health care costs. More often than not, laboratory and imaging tests are repeated unnecessarily because we don't have the results from another hospital or clinical setting or are unable to personally view imaging ourselves, such as chest x-rays or cat scans. This isn't good for the patient either, as multiple blood draws can introduce more infection or deplete already sick patients of their blood, and expose patients to more radiation than necessary.

Unfortunately, the costs to implement such a system are also enormous. The majority of hospitals still run on a paper system and of the hospitals that are on an electronic system, very few of them are 100% paperless. Moreover, these hospitals all run on separate systems. To get all hospitals on the same electronic system would be incredibly time-consuming, logistically a nightmare, and costly beyond belief. During the transition, there would probably be many records lost, confusion regarding how to access records or results and much worse and slower health care. The hospitals themselves probably all have their own systems in place already and would be reluctant to switch to yet another system, especially if they just spent all this time, effort and money to implement their own electronic system. Many hospitals would probably just want to make their system compatible with whatever universal system is being implemented, which is not ideal. And who would pay for this? The government?

Despite all the roadblocks, I still think it's a worthwhile investment, and hopefully the eventual benefits would outweigh the costs and the inconveniences and temporary lapses in health care.

Zahav

We went to Zahav last night for restaurant week. It's supposed to be a modern Israeli restaurant, and it was spectacular. A nice treat on a non-call and non-post-call night. Sometimes restaurant week is hit or miss because some restaurants become overloaded with customers and they're not used to - so the service goes downhill as well as the food. I think the really good restaurants though, ones that are often busy all the time and are used to the customer load, do just as well during restaurant week as they do during other times.

Last night, they started us off with some pickles and olives, and then brought some large trays of amazing hummus with this homemade bread called laffa that reminded me of naan. Then they brought an appetizer of 8 different vegetables/salads prepared different ways: pickled turnips, beets, carrots in a peppery marinade, cucumbers, a pepper pesto, eggplant, and a couple other things I can't remember off the top of my head. They were all excellent - the beets were my favorite, as well as the table's favorite.

Then we each got to choose two appetizers and an entree. As you can imagine, there was a lot of sharing. I personally ordered the fried cauliflower (one of their specialties) and mini stuffed peppers. The fried cauliflower was soooo good. Pete got bulgar wheat stuffed with ground lamb (sort of like an empanada) and chopped liver. It was probably the best chopped liver I've ever had. From other people at the table, I also tried the fried sheep's milk cheese, which was amazingly tasty and rich, and also these leek and mint fritters, which were mild, but I thought really really good and creamy.

For entrees, we all got similar items. I got a ground beef and lamb entree (the "bulgarian) while Pete got a ground beef and lamb sausage ("Monsieur Merguez"), which was very very tasty, with good spiciness and texture. Then for dessert we shared a cashew baklava with white chocolate argan ice cream and a "konafi" which looked a little bit like sugar and chocolate deep fried noodles, topped with ice cream.

I think I'm still full. :)

Interviewing

It's coming to the end of the interviewing season, thank goodness. :) For the last couple of months, with a break for the holidays, Pennsylvania hospital has been interviewing candidates for next year's intern class on Wednesdays, Thursdays and Fridays, about 10-20 4th year medical school candidates each day. It's somewhat interesting to see how a program recruits good candidates.

Of course, the program reputation speaks for itself - either for good or for bad. Word of mouth goes a long way, and during the day, they give the candidates ample opportunity to speak to current residents and interns and ask them questions. I, for one, believe in being completely honest about everything, even if that puts the program in a bad light. Of course, I tend to look at things more positively than others, I think, so I may be putting a good spin on things unintentionally. I think it's a bad sign when a program doesn't give you time to spend with current residents and interns - what are they afraid of?

More interesting to me are the little things that candidates care about that draw them to or away from a program. #1 thing is the food. I can't tell you how many times the subject of food or how well candidates have been treated during the interview comes up or plays a role in their decisions. Logically, this should have nothing to do with someone's decision to join a program, or how good the program is, but if crappy food is served during the interview, candidates notice! It's worth noting that on the days that preliminary candidates come to interview (these candidates are internship candidates that, instead of staying in an internal medicine residency for 3 years, are in the program for one year and then go on to a specialty like radiology or opthalmology), the food is much better because good preliminary candidates are thought of as much more competitive and more difficult to draw to your program.

Other little things include paying for parking, taking you out that night with other residents, etc. If a program goes so far as to pay for other things, like hotel costs or travel costs, that's even more impressive to candidates. I think for most people this plays out during residency too - in the end, many people are concerned not just with the training they receive during residency, but their quality of life during residency which includes all these "little things."

Our litiginous society

I've known for a long time that there's a problem with the medical legal system in this country that needs to be fixed. However, I recently heard this story that rams home the point.

There was a patient who had multiple medical problems and normally is seen by doctors at the hospital medical clinic. Due to various reasons, usually the clinic is used by patients who have little insurance or bad insurance, and so they cater to many of the inner city population. The doctors rotate there as well, so continuity of care is not always the best, and the patients don't often follow up with their appointments. The clinic is often also abused, with people walking in constantly without appointments and expecting to have 10 different medical complaints addressed in a single visit.

At any rate, for reasons I won't go into, this patient had to be anticoagulated - that is, her blood had to be kept thin with medications so that she would not develop a clot. Clearly a clot can be a very bad thing - it can travel to the heart and cause a heart attack, it can go to the brain and cause a stroke, it can go to the lungs and cause a pulmonary embolism or a "lung attack". So it's important that her blood is kept thin so that the clot doesn't get any bigger and perhaps would even dissolve away eventually. However, as with any other medications, there are risks. The particular medication you use as an outpatient (coumadin) needs to be monitored closely. The levels are usually tested every 1-2 weeks at an outpatient laboratory or clinic, and if your blood is too thin, there is certainly a risk of bleeding. This can be very serious as well, causing yet another type of stroke, or patients can lose so much blood that they become very sick or die. So monitoring the level of coumadin in your blood every once in a while is very important until you reach a good regimen that keeps you consistently at the right blood thinness.

This woman had been admitted to the hospital several times in the last several months for unrelated issues, and each time, her coumadin level was not right. Sometimes her blood was too thin, and sometimes it was not thin enough. They would always get it just right before sending her home and tell her to follow up at the hospital clinic to get it checked out a week or two later. Sometimes she did this, sometimes she didn't. Finally, one particular instance, she was supposed to be seen at the clinic and missed her appointment. Two weeks later, she was admitted to the hospital where her blood was much much too thin, she started bleeding, and bled so much that she ended up dying.

Her relatives are now suing everyone that has ever been involved in her care, including a cardiologist who saw her only once during one of her hospital stays, an excellent medicine attending who saw her once at the clinic 2 years ago, and doctors from other hospitals as well who have been involved. Even though there has been no wrong-doing on anybody's part at all, and their lawyers agree they could win this case, pretty much everyone involved (and their insurance companies) has finally decided to settle out of court and pay instead of fighting this because it would be much cheaper. Just as an example, it would cost them $2 million to fight this battle in court after all the lawyer fees, etc whereas settling out of court they pay the family $200,000. Easy money for the family.

The only point someone brought up is that when the patient missed her appointment, nobody called her to ask her to come in or to reschedule. But is that our responsibility? Patients get a reminder call, and when they don't come in, I don't necessarily think it's the health system's responsibility to beg them to come in. At some point, you have to ask the patients to take responsibility for their own health care and participate.

This story exemplifies one of the reasons why health care costs so much for everyone. The $200,000+ that the family won (which doesn't even include the doctors' time, paperwork, other court fees) is basically being paid by all the other health care users out there. There needs to be some sort of reform within the medical-legal system. I don't have any great ideas, but something needs to be done.