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.

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.

God and medicine

I'm not particularly religious, but I know many patients and doctors are. Although I don't believe in the same thing they do, I feel that I have plenty of respect for their beliefs and don't usually have a problem with it. However, I have a small pet peeve about something I hear a lot of patients say. It's not a big deal, really it isn't, but I dislike it when there's a test or therapy patients don't want to take and they say "it's in God's hands." I completely respect patients' wishes (and sometimes agree with them) when they don't want to take something or do something - it's their right. However, I have a problem with them using God as an excuse. I'd rather them tell me they just don't want to do it, even if it's against all logic, than use what I call the God excuse.

For one thing, it's contradictory. The very fact that they came in to the emergency room or the hospital means that they do not completely believe that "it's in God's hands." Why go to a doctor at all? The very act of going to seek medical help means you believe that you can change what happens to your health and that maybe you believe that it's not all "in God's hands." If you truly believed that, you would just stay at home to live, die, suffer at will.

But it's not a big deal. For whatever the reason, whether it be religious or not, we respect what the patients want.

The neverending bag of patients

I have had a lot of patients on my list everyday - nearly the max an intern can carry. Today I discharged four patients. That's a lot. But it didn't matter - I admitted another four in the afternoon into night, and there will probably be another one I get there in the morning.

Sigh.

Patient Rights

Informed consent. It's a long history, but informed consent came about when patients started asking for more autonomy in their patient care and the term "patient rights" came into being. I'm all for patient rights and autonomy and it's definitely the right direction for patients to go towards. Of course, there has to be a limit to what a doctor can or has to do, and this article does an excellent summary of listing and explaining common myths about informed consent:

http://archinte.ama-assn.org/cgi/content/abstract/156/22/2521

Let me summarize.

Myth 1: A signed consent form is informed consent. Just because somebody signs a piece of paper saying they understand all the risks and potential complications of a procedure doesn't mean that they understood everything you tried to tell them, or everything that's on that piece of paper. Some of those consent forms are pages and pages long and full of jargon, so that could actually confuse someone more than it helps.

Myth 2: Informed consent is a medical miranda warning. There's more to informed consent then tell patients all the risks of a particular procedure or action. You also need to tell patients about options, potential outcomes, etc.

Myth 3: Informed consent requires that physicians operate a medical cafeteria. For a given problem, there might be 20 different ways of going about treating it or solving it. A doctor doesn't actually need to present all 20 ways - in fact, this usually confuses the patient! The doctor only needs to (and should) present a couple of the methods (usually what the doctor thinks is best) to the patient and information about the different methods. And physicians can still give advice - the goal is just to not be paternalistic. In fact, patients often ask for advice ("what would you do if you were me") in addition to the information and welcome it. Doctors don't have to just sit back and let the patient choose out of all the options with only factual information.

Myth 4: Patients must be told everything about the treatment. This is certainly not legally required, and if doctors did this, it could take hours. Ethically and legally, a doctor should tell a patient everything a "normal" patient would want to know, and then of course, ask if the patient has any questions. A doctor cannot and should not be sued or deemed a bad doctor because he failed to disclose an aspect of the treatment that is very rare or that the common patient wouldn't care to know at the beginning.

Myth 5: Patients need full disclosure about treatment only if they consent. Theoretically, patients need to know about important things before they consent if they are trying to choose between options.

Myth 6: Patients cannot give informed consent because they cannot understand complex medical information. While a patient might not be able to remember or recall everything that was explained in the office, during that office visit, they will probably understand everything well enough to make a decision. Secondly, things need to be simplified in a way that patients can understand things. If a patient is incapacitated or incompetent in a way that makes them unable to make decisions for themselves, then there needs to be a surrogate decision maker.

Myth 7: Patients must be given information whether they want it or not. It is certainly within a patient's right to not participate in decisions affecting their health care - they may leave it up to a family member, or even their doctor. The doctor shouldn't force a patient to listen to them if the patient truly wants to give up this right.

Myth 8: Information may be withheld if it will cause the patient to refuse treatment. In no instance is it right to withhold health information from the patient about him or herself.

I think this article is great, because often doctors feel they have to tell the patient too much, or there are doctors not telling patients enough. Conversely, there are patients who expect things that doctors aren't obligated to give. Of course if they ask, it is usually given, but just because a doctor doesn't give it, doesn't mean they're a bad doctor. The article basically explains to both doctors and patients what is expected of them during an office visit, and that's been a relatively murky issue for quite a while - at least in my mind.

Prisoners as Patients

We were on call today and miraculously got no patients!!!! It’s the first time ever! I was pretty excited. :)

I’d like to mention a special subset of patients we have at Princess Marina – the prisoners. There is a prison near Gabs (which we actually saw on the way to the Kalahari) that often sends prisoners to us for medical treatment. There is a small clinic within the prison but I think they can only treat patients to a very limited degree – so for very sick prisoners, they send them to PMH, shackled at the ankles, along with at least one prison guard.

You never really find out what these prisoners were jailed for. Boipelo and Maggie (another MO) told us that it’s mostly small things, like theft, but occasionally there are murders (usually crimes of passion, or as they say, “passion killings”) and rapes. Sometimes if a prisoner comes with two prison guards, I think that they must have committed some more offensive crime. But we treat them all the same. They stay shackled with these old-fashioned metal chain shackles, and anywhere they go, a prison guard goes with them. Some of them are relatively healthy and walk around everywhere, while others are incredibly sick and stay in bed all the time – it’s interesting because they stay shackled no matter what, even if they’re too sick to move!

Most of the prisoners are pretty sick by the time by the time they come to PMH. I think the prison clinic does everything it can to help them and then sends them to the hospital only when absolutely necessary. There probably is a huge incentive to fake illness – PMH is like a vacation for these guys. They get mattresses, decent food, and they can even have visitors at PMH!

A high percentage of the prisoners are foreigners, especially Zimbabwean. It’s actually a big problem because foreigners don’t get the same medical treatment that Motswana prisoners do. Because they aren’t citizens, they can’t get CTs without paying (and it’s expensive!), and they can’t get free HIV or TB medications. One patient I had was diagnosed with HIV in prison a few months ago, and is starting to get these complications from AIDS. These are mostly due to opportunistic infections, like Cryptococcus, or TB, and if you get them, it’s a sign that your CD4 count is pretty low and you need to start HIV medications as soon as possible. If this patient could just start taking HIV medications, then it would be ok, his immune system would recover enough for him to fight off the infections on his own. But since he’s a foreigner, he can’t get the free medications from Botswana, and obviously he’s in jail, so he can’t make any money to pay for them. If he was out of jail, he might be able to make enough money, either here or in Zimbabwe, to pay for medications, but here he’s just out of luck. It’s a horrible situation – I don’t know how much jail time he has left to serve, but he might die in there just because he can’t get the HIV medications.

The supply chain in Botswana

This was a relatively boring day at the hospital since this is our easy week, so maybe now I’ll talk about some another issue at the hospital – the supply chain! This is a favorite topic of Dr. Stefanski's, so we've had quite a few discussions about it.

So here at Princess Marina Hospital, probably the largest public hospital in Botswana, there are often problems with the availability of medicine, or of certain medical instruments, even very common ones. Last week, we ran out of amphotericin, which is a drug we use to treat cryptococcal meningitis - that's an infection in the cerebrospinal fluid that surrounds your brain and spinal cord. It's the type of thing that we diagnose with an LP, which I described in previous posts. Because a lot of people have HIV and AIDS here, a lot more here come down with meningitis than in the states - some of it is due to TB, some bacterial, some bacterial, but more often than not, it's due to cryptococcus. And amphotericin is really the only option they have in Botswana to treat it. Alternatively, you can use a whopping dose of fluconazole, but it doesn't work as well, and we also ran out of that for a few days last weekend. As a result, all these people in the hospital (and in the clinics probably) had no amphotericin, and also no fluconazole - their cryptococcal meningitis went untreated! Now, even if they had come in immediately and started treatment right away, this is an awful disease, and chances are not great that they'll survive. But if treatment is delayed or halted for a couple of days, chances are even worse! Our team didn't have anybody die, but I know other teams that did.

Dr. Stefanski told us this story about how last year, they ran out of the solution needed for peritoneal dialysis, which is a substitute for your kidneys, if your kidneys have failed. Dialysis isn't as common here as in the states, but there are still quite a lot of people on it. And they were out of it for a month! People were basically getting admitted to the hospital to die of kidney failure. Awful.

Apparently, the problem is not lack of money - the ministry of health has plenty of money. It is the largest ministry in Botswana, and controls the largest budget by far. The problem is that somebody or some group, whoever is in charge of ordering medical supplies for the country, did not realize that we were running low on drug X, or medical supply Y, and didn't order it. So the entire country will be out of whatever it is for a month at a time! Supposedly, they've had 3 big consulting companies (probably each making millions of dollars each time) come in and make suggestions as to how to correct the problem, but obviously that hasn't happened. It seems that every time there is a change in who's in charge, they get a new consulting company in (probably they're friend or relative's company) and get new recommendations, which aren't followed. It's such a ridiculous problem, and a very exasperating one that all the doctors complain about. I guess it's another thing to be thankful for in the States.

The hospital crowd

So more about the patients and the hospital… Working at the hospital has definitely been an interesting experience! The patients here are so different from the patients in the U.S. There are usually 8-10 patients in a cubicle, with about 5 cubicles in each ward. Often, a small office gets turned into a 6th or 7th cubicle to cram another 5 patients into. Sometimes patients don't even have a bed, they have a mattress on the floor, sometimes in the hallway, if it's too crowded. The ER never closes because the hospital is too full, you just squeeze more patients in. There is absolutely no privacy - you're lucky if you get a curtain to draw around a single patient. You do procedures at their bedside, often with other patients looking on. The picture below is one of the better cubicles (the "high-intensity" cubicle for sick patients - which is right in front of the nurses station should a patient need immediate attention) on a very uncrowded day. There are no patients on the floors and there are a good number of curtains up.

So the patients are crowded together, usually not more than a foot from each other, they have no TV, no books, nothing, and visiting hours are only from 6-7:30am, 1-2pm, and 4-5pm and 6-7:30pm every day. And surprisingly, the hospital and the nurses are very strict about the hours. So right at 1pm, all these friends and family stream in, and right at 2pm, they leave. They're actually sort of necessary because the hospital is so understaffed that often the family helps bathe the patients or feed them if the patients can't feed themselves. The patients come in pretty sick too, because they often don't want to go to the hospital until their symptoms are super bad. Despite all this stuff, the patients rarely, if ever, complain. They just sit there everyday and wait patiently for us to come see them, and to get better. It's such a change from the U.S. patients, who have such a sense of entitlement, and demand every little thing, even things like mashed potatoes for dinner or something.

Patients rarely sue anybody here, and they put up with a lot more crap than do patients in the U.S. I guess that’s necessary because I think mismanagement of a case is pretty common. I think there are a variety of reasons for it – number one being the fact that the hospital is way understaffed. There are not enough doctors, nurses, social workers, physiotherapists, anything you could possibly think of. I also believe (and this is almost definitely egocentric) that the doctors and nurses here are not as well-trained, and so there is some medical mismanagement because of that. The Penn people are very good, but the other doctors sometimes are just here to do their job and make money (not that it’s a huge amount) – they don’t put in the effort to learn, teach, or really help patients get better. I’ve seen so many patients come in with congestive heart failure get put in fluids, or people with focal brain tumors that are obvious on physical exam, get diagnosed with meningitis. It’s a little embarrassing sometimes. Of course, when you get 10 admissions in a night, and are covering 100 other patients, sometimes it’s difficult to do an appropriate workup of a patient. But still, the lack of knowledge can be appalling.

There’s this one M.O. (a doctor who has only finished internship only) the other day who was getting grilled about a patient during intake as she was presenting. The patient had right upper quadrant abdominal pain, and she gave her differential diagnosis as pneumonia. Horrible. When the chief of the hospital asked her what else it could possible be, she could only answer pneumonia… so then he asked her what organs might possibly be in the right upper quadrant. She said spleen. And that’s all she could come with. And this is a doctor! Awful.

The nurses here are also very different. They don't do much here - they don't do IV's, blood draws, put in foley catheters, etc., so you have to do it all yourself. Believe it or not, I actually miss the nurses at HUP. :) I guess some things are still the same – some nurses and good, some are nice, some are moody, some refuse to do anything. There’s a whole variety.

The diseases we see here are different too - we see a ton of HIV and advanced AIDS-related illnesses here: TB (which can be anywhere), cryptococcus (which can be anywhere), PCP pneumonia, different cancers. I'd say about 75% of my patients are HIV positive, which allows a lot of this other stuff (TB, PCP, cancers) to happen. Botswana actually has a free HIV medication program (which is a whole separate topic for a different day) for all of its citizens. Even so, many of the patients refuse to take their medications and instead take traditional medications. They’ve caught patients throwing their medications down the toilet or in the trash before. And sometimes these traditional medications – we have no idea what they are – cause kidney failure or liver failure! I guess that’s the most frustrating thing about these patients, even though they are super nice and appreciative, and their families are by and large amazing in terms of support.

In general, there are so many patients you just can't take care of all of them - some stuff just has to slip through the cracks and you have to let it go. You're already working twice as hard as many of the Botswana doctors and at some point you have to go home, but that means some patient is probably going to die. Luckily I didn't have anyone die on me for my first two weeks, but it's really just luck - almost every team has an average of one patient die every day or two. I will probably have a patient die on me this weekend because there’s less care during the weekend. There’s usually two people covering all 100 patients, and they are really only required to see the sickest ones. It’s also difficult if they admit 10-30 patients over the weekend to see the other sick patients already on the ward – they are just so busy! However, other people just don't take as good care of your patients than you do when you're actually at the hospital. And any signout you give to the covering doctor doesn't usually get done, but it depends a little on who you sign out to and who’s covering the weekend. I guess these things are just things you have to let go because you can’t be at the hospital all the time.