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...

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.

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.

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.

Scrubs

An interesting article in the New York Times sent to me by my mother-in-law:

In case it won't let you read it, here it is:

Should hospital scrubs be worn in public places?

That’s one of the questions asked by my Well column this week, which looks at the role clothing may play in the spread of germs by health workers. The issue of scrubs on the subway and other public places has been raised often by readers of the Well blog.

“I cringe every time I see a medical professional on the subway in their scrubs, which is a regular occurrence,” writes reader A.K.

“What drives me crazy is the sight of someone wearing scrubs while shopping for groceries, going to the post office, picking up their kids from day care, and so on,” writes Jenny, a nurse. “Someone wearing scrubs has been around germs all day. That person is too lazy to keep their patients’ problems away from you, and now they’re handling the apples and cereal boxes that you or someone you love may handle next.”

As my story explains, there’s no evidence that wearing soiled scrubs out of the hospital poses a threat to the public, but part of the problem is that the issue of physician attire and germs hasn’t been well studied. To read more, read the full Well column here, and then post your comments below.

I think the best part of the article are the comments below it from readers - not surprisingly, I agree and sympathize with the doctors. If you work in an operating room, or somewhere that requires clean clothes for the patients' sake (for example if they are all immunocompromised), even if you wear scrubs to work, you have to change into new clean scrubs at the hospital, which you take off before you leave. Otherwise, scrubs are no different from other clothes (for example a suit) that you wear to the hospital. It's really just a public perception that they are dirty - people wearing nice clothes touch the same patients, do the same procedures, go into the same areas of the hospital as people wearing scrubs. From my own perspective, if something happens to a patient and we have to do something emergent, or there's some blood spilled during a procedure, it is easier to clean scrubs than it is to clean a suit or a nice blouse, not to mention that scrubs are often much more comfortable and allow me to do procedures without restriction or care about my clothes. Although not relevant to the safety issue, I also agree with some of the other comments saying that many non-medical personnel wear scrubs too just because it's convenient, and these people often include janitors, technicians, medical students, researchers, etc. In the end, I guess what would be needed to settle this point is a study looking at people wearing scrubs in the public compared to other medical and non-medical people wearing regular clothes and seeing if there are any differences in "germs", and moreover, even if there were differences in amounts or types of germs, if this actually made any difference in terms of infection rates of people they came into contact with. I doubt anyone is willing to spend thousands of dollars to find something like this out.

Steps involved in medical care

I'm at a conference right now, and one of the keynote speakers said something that inspired this post - he said "Think how many health care professionals it takes to take care of someone when they're sick." It's hundreds. Let's just go through an example, one I'm relatively familiar with.

A woman - let's call her Mrs. Smith - finds a lump in her breast one day. So the first thing she does is go to her family practitioner (health care professional, or HCP #1). At the doctor's office, she's greeted by a receptionist (I won't count this person as a HCP) and a nurse takes her vitals or her visit information (HCP #2). The doctor feels the same lump during that visit, gets concerned and sends her for some bloodwork and a mammography. Mrs. Smith has to go get the bloodwork done at an outside lab because of her insurance and there a tech or perhaps another nurse (HCP #3) does it for her. At least one technician (HCP #4) performs the labs and sends the results back to the primary care provider. For her mammography, Mrs. Smith probably has to go to a different hospital or radiology center for her mammography. There, one or two techs (HCP #5) do the mammography, then they send the results to a radiologist (HCP #6) whom Mrs. Smith may or may not ever meet! Unfortunately, the radiologist sees a suspicious lump in the mammograph and sends his findings to Mrs. Smith's family practitioner. She goes back to see him (her second visit, at the very least) and of course, he's very concerned and sends her to an oncologist (HCP #7).

At the oncologist's office, she meets more receptionists and nurses (HCP #8) who take her info first, and then she meets the oncologist (HCP #9). The oncologist feels the same lump, looks at the mammography findings and says she needs a biopsy. The first biopsy they usually do is relatively simple. The oncologist inserts a needle into the mass, sometimes under ultrasound guidance (sometimes requiring another tech or radiologist) and gets some tissue, which gets sent to a pathologist (HCP #10). Often, the first biopsy isn't good enough and they need to do the biopsy a different way, or get someone else (another HCP) to do it. Let's say in this case, the biopsy sample was good enough and the pathologist says it's cancer. The pathology lab has some other techs and pathologists (HCP #11) who do additional studies on the biopsy sample to characterize what type of breast cancer she has. On Mrs. Smith's second visit to the oncologist, he tells her the bad news, and tells her she will have to have it removed by surgery, and because of the characteristics of her cancer, she will also need radiation and chemotherapy. The oncologist has now become her center of health care, and he sends her to a surgeon (HCP #12).

Again, at the surgeon's office, she meets another nurse who takes her vitals signs and her initial information (HCP #13). The surgeon says yes, we need to do surgery and after some more bloodwork and probably some cat scans or additional imaging, she's ready. Mrs. Smith gets admitted to the hospital the night before the surgery, and meets at least two nurses who take care of her while she's there (HCP #14 and #15). There are also techs who take her vital signs and may administer medication (HCP #16 and #17) as well as a tech who normally does blood draws (HCP #18) for routine labs in the hospital. Because she's in a hospital, a different lab and a different tech runs her bloodwork and interprets them (HCP #19), and she may have a different radiologist (HCP #20) interpreting her imaging studies. There is also at least one pharmacist (HCP #21) involved in giving her the correct medications at the correct times. Moreover, there are healthcare-specific social workers (HCP #22) checking her medical charts and information and making sure things are overall being done correctly. The next day, she's wheeled off to the O.R. (operating room). Before anything is started, she meets the surgeon again as well as the anesthesiologist (HCP #23). In the operating room, there is of course, the surgeon and the anesthesiologist, but there is also a scrub nurse (HCP #24), a nurse in the room (HCP #25) helping get extra supplies, answering phones, etc., and at least one resident or physicians assistant (HCP #26) helping the attending surgeon. After getting out of the O.R. the patient usually goes to a PACU, or basically a recovery room, where there are at least one or two other nurses that help her (HCP #27). From there, Mrs. Smith would probably go to the medical ward where other nurses and techs take care of her (HCP #28, #29, and #30) and the surgeon and his team (probably his resident or assistant) visits her to make sure she's okay after surgery. Hopefully there are no complications and she leaves the hospital within a day or two to go back home. Meanwhile the hospital pathologist (HCP #31) examines her breast tissue under the microscope, and a lab technician or another pathologist does further biochemical work to characterize her cancer (HCP #32).

After she's recovered from her surgery, it's time for her to start radiation therapy! So now her primary care provider refers to a radiation oncologist, at who's office she is again first greeted by a nurse (HCP #33 and #34). They get her set up with a planning cat scan, which is done by a tech on a second appointment (HCP #35). The radiation oncologist plans her therapy on a computer, which is assisted by a dosimetrist (HCP #36) and a physicist (HCP #37). Radiation therapy usually takes many many weeks of daily Monday through Friday treatment, over which time Mrs. Smith will meet many technicians, nurses and other doctors (HCP #38, #39, #40).

Finally, it's time for chemotherapy. Although this may again take a number of weeks, this is done through her oncologist's office, where she already has probably met the nurses and assistants that will be involved in her care. Depending on the type of chemotherapy Mrs. Smith receives, she may meet some new HCP's in a chemotherapy room or who help her to administer the chemotherapy at the office or at home.

As you may have noticed, even though I probably grossly underestimated the numbers of HCPs that helped Mrs. Smith out, in the story itself, that's a total of 40 health care professionals who have all helped Mrs. Smith during her medical problem! This story doesn't even take into account residents, medical students, nursing students, medical transporters, and other health care professionals who often play a large role in a patient's care and may more than double the number of HCPs who help her! Moreover, this story was relatively straightforward, and the patient didn't experience any complications, such as infection, adverse effects from chemotherapy or radiation, biopsy problems or anything else, which would of course result in more diagnostic procedures and treatments, as well as exposure to more HCPs. In addition, Mrs. Smith may have other medical problems and comorbidities not mentioned in the story which require the attention of even more HCPs.

The entire reason for this story is that I think it is amazing how many health care professionals are involved and how many steps are required for providing basic care for what has become a relatively commonplace problem. With this consideration, it seems like it would be a miracle if everything went smoothly, nothing went wrong, and the patient was satisfied with absolutely everyone that helped her out. It seems healthcare is so complex in the modern world that there will always be room for improvement despite continual modifications, and from the standpoint of a health care professional, I hope that patients realize all our efforts to streamline the process and make their own healthcare easier for them to go through.

Doctors and arrogance

I know a lot of arrogant doctors. I probably am an arrogant doctor. It's probably a good general statement for lawyers and businessmen too, but it's definitely a trend in doctors.

For one, I think it's a self-selecting group. Not many people can say that they want the responsibility of caring for someone else's life. And if you think about it, it takes a certain amount of arrogance to think that you are capable of doing such a thing. In fact, it takes an even greater amount of arrogance to do something wrong the first time around (potentially really affecting someone else's life) and try to do it again. But the surgeon who started the first heart transplant failed something like 5 times before he succeeded. Meaning the first 4 times, someone died. It takes a lot of guts to keep doing something like that with those potential consequences. But in the end, it can mean great strides in medicine positively affecting the lives of thousands of people.

Secondly, I think a certain amount of arrogance can be good for doctors as well as patients. If a doctor had a personality that beat themself up every time they made a mistake, they wouldn't survive. Every doctor makes mistakes once in a while, no matter how good they are. Some mistakes of course are more costly than others. But in the end, you have to be able to move past it, learn from it, and never ever do it again. On the patient care side, the last thing any patient wants to see is that his doctor is uncertain. If a doctor is undecided about a certain course of action, of course they should admit it, but once a course of action has been decided upon, the doctor should be very confident about it. I think if a doctor is visibly uncertain about something, that definitely adds to the patient's stress. I think it also makes the patient lose confidence (subconsciously) in the doctor's ability to make medical decisions, etc.

I guess whether good or bad we're stuck with it.