ACP Internist Blog

Monday, February 24, 2020

The lions for lambs of health care

I just watched the movie “1917” in the theater. Shot in a unique way giving an immersive experience, showing the frontline reality of war through an unforgettable human story, it has to be one of the greatest war movies ever made. I'd encourage everyone to go watch it. I learned a fair bit about the WWI while I was in high school in the United Kingdom. Its stories are often eclipsed by the much larger-scale WWII, which came two decades later, but many historians will argue that it was the WWI which was more horrific and shook the world to a greater degree, because it was the first time industrial-scale technology had been brought to the theater of war.

The horrors of trench warfare are described so vividly by many of the great poets of the time, like Wilfred Owen and Siegfried Sassoon. And unlike WWII, which actually did have an obvious evil enemy and despicable ideology worth fighting against, the WWI was more about stalemate between sides that didn't really know why they were even there. A war that became drawn out because of the sheer arrogance of the leaders. Millions of brave young men from Britain were killed, wounded or maimed. There are monuments all over England, even a large one right in the middle of my small Berkshire village. When you look at the ages of those who died, many are barely men at all; they are just teenagers. Such a waste of young life.

There's a famous quote by a German general who was witnessing wave after wave of brave British soldiers being sent over the top of trenches to their certain death, as they were mowed down by machine gun fire. He remarked: ”Never before have I seen such lions led by such lambs.” That quote came to represent many of the catastrophic leadership decisions of the British hierarchy, who kept making miscalculations and taking needless risks with human life, all for gaining sometimes just a few feet of enemy territory. The British army knew that they were being led badly by their generals, and actually coined a slightly different version of this phrase: Lions led by Donkeys.

I like these quotes for many reasons, because they can be applied in a multitude of different ways today, especially to modern leadership. Needlessly to say, nothing could be as consequential as war and death. And nobody could be braver than a soldier. However, when the frontlines are let down by their leadership, what happens from there is never going to be good.

Leadership is lacking all around us, in so many industries and sectors, and nowhere more so than health care. The consequences are right in front of our eyes: a suboptimal fragmented system, soaring costs, hidden agendas, and a demoralized group of people who work in it. If you have a leader who is not with their frontlines, an earthquake will be felt down the whole chain.

As a physician who has worked in dozens of different institutions in different parts of the country, I have sadly seen some terrible examples of leadership, from mid-level managers all the way up to CEO. Fortunately my experiences have led me to now only choosing the very best-led places to work in, because I can sense in an instant anywhere that doesn't have a good leadership team in place. (I even want to speak with the CEO before I consider signing any contract, to gauge their character and core beliefs.) From what I have seen, these better places are in the minority in the health care world.

There is a scene in “1917” when the soldier who is trying to deliver an important message from high command to a senior colonel, to halt an attack, interacts with a senior British officer, who cleverly tells him, “Make sure there are witnesses when you deliver your message … because some of us just want the fight ….”

That was a very shrewd thing to say, because there are sadly leaders who will always be more interested in advancing their own agenda, and will gladly sacrifice others to do so. We have all seen it, and I'm sure everyone reading has their own stories about managers who are all about numbers, targets, and the bottom line. I have personally seen many leaders gladly throw a doctor group or nursing team under the bus to look good themselves. And all the while the clinicians know that none of them would even last a day, if they ever had to do what we do.

The frontline workers in health care are heroes. There's no other word for them. They are lions. The doctors, nurses, and all other professionals. They will always do their duty no matter what. Moreover, their hearts are in the right place. Sadly, that is often taken advantage of. They could be exhausted, understaffed, or being led badly, but they will never neglect that patient in front of them and always go the extra mile, all of this while their immediate world may be consumed by corporate greed, politics, industrial disputes, and patients who are suffering.

Everyday across this great nation, frontline clinical staff are let down by their leaders. Whether it's the administrators or politicians, it's true in health care too: Rarely will you ever see such lions led by such lambs.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Friday, February 21, 2020

There is too much technology in medicine

As promised, here is the continuation of last week's post where I discussed the loss of physicians' diagnostic skills which have been largely replaced by technology.

Of course, the medical community celebrates the miracles that technology has brought us. Innovation has improved our lives and will continue to do. On this issue, there is no debate. But, as with many advances, there is a cost. Here's my take on the downsides of the technologization of the practice of medicine.
• Overreliance on technology has cost zillions of dollars.
• Much of the overdiagnosis and overtreatment in our health care system, which I have decried on this blog, is caused by medical technology.
• Technology has strained the doctor-patient relationship. It is often easier to order a scan than to have a deeper conversation with patient who needs advice and counsel, particularly when physicians' schedules are jammed.
• CAT scans and their ilk regularly find unrelated “abnormalities” that would remain dormant for life, but now assume a life of their own as doctors must pursue them.
• Technology is not perfect, even though we all tend to regard it as the Holy Grail. A negative test result may blind us to the truth if we are not vigilant. A patient with stomach pain and a normal CAT scan can still be in deep trouble.
• Patients have taken heed of our technology obsession. They regularly ask their doctors for testing that they may not need. Every doctor has had a patient facing him insisting that a CAT scan be done. The public understandably believes that more testing is better medicine. Of course, this is false premise but try convincing a patient and their family of this. I know from my own family; they don't get it and the medical profession and our payment system is responsible for it. (Patients are more enthusiastic for testing that the insurance companies will pay for)
• There are financial conflicts of interests that drive the overuse of technology. Yes, medicine is a business and we would should expect that the normal forces of profit seeking are operative.
• Technology has not only eroded physicians' physical exam talents but has also diminished doctors' skill and enthusiasm in obtaining patients' medical history, the important narrative that the patient communicates to the physician.

I often hear and read presentations of patients' medical history where the third sentence is “… and the CAT scan showed …” This premature intrusion of a technology result, a physician spoiler, immediately prejudices the doctor who should have been given time just to hear the patient's own story. If you are told in advance of an important future development in a mystery story, will you still read the book as carefully as you would have otherwise? The danger for doctors who are given a sneak preview of events is that we become less attentive and vigilant which can lure us into false passages.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Friday, February 14, 2020

Can doctors still examine patients?

Does your doctor really know how to use a stethoscope or palpate your abdomen?

Today's physicians do not have the physical exam skills that our predecessors did. We can argue if this truth has diminished medical quality; I'm not sure that it has. But it has completely changed how medicine today is practiced. The reason for declining physician exam skills is that technology has largely supplanted physicians' hands, eyes and ears. In the olden days, the stethoscope was the diagnostic tool for examining hearts. I spent a month as a medical student with a legendary cardiologist who could make all kinds of cardiac diagnoses right at the bedside using 2 advanced medical instruments known as ears. Surgeons and gastroenterologists in years past had to make diagnoses of acute appendicitis and other abdominal emergencies based on feel and their ‘gut’. Neurologists made accurate diagnoses of stroke just using their clinical skills.

These days, there is really no need to be sleuth with a stethoscope since any murmur or extra click will be followed by an echocardiogram. I can't recall a case of appendicitis in my career that didn't involve a CAT scan to confirm a surgeon's suspicion. And, if a stroke is suspected, a head CAT scan will be arranged.

Since, medical technology has in many cases taken over the physical examination, doctors' hands-on skills have decayed. There is much less pressure for our exam skills to be superb since we know that some rescue scan or diagnostic test that does it better will follow. Conversely, if a physician were seeing a patient with stomach pain, and there was no technology available, I surmise that this doctor would do a more careful exam than he otherwise would. Get my point?

Are patients better served with more accurate technology to make and exclude diagnoses? Some have and many haven't. We all celebrate how technology in medicine has revolutionized the profession and has saved and improved lives. I rely upon this every day in my practice. But we must acknowledge that this progress has exacted many costs.

What's the harm with ordering a CAT scan? After all, it's non-invasive. Next week, I will address this issue in detail giving you a true “peek behind the curtain,” the raison d’etre of this blog. Feel free to offer your own thoughts on this issue on this post in advance of next week's full disclosure.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Friday, February 7, 2020

Can a doctor do a medical procedure without consent?

Some time ago, I performed a colonoscopy on a patient who was having serious internal bleeding. He had already received multiple transfusions since he was admitted to the hospital. After obtaining informed consent for the procedure, I performed the colon exam. I encountered blood throughout the entire colon, but saw no definite bleeding site, raising the possibility that the source of blood might be higher up than the colon, such as from the stomach. I had not considered this possibility when I met the patient, but this was now plausible. Can I proceed with the upper scope test, which the patient did not consent to, while the patient is still sedated from the colon exam?

Seasoned gastroenterologists can usually predict the site of internal bleeding based on numerous medical facts, but there are times that we are surprised or misled. Patients don't always behave according to the textbook presentations we learned.

At this point, which of the following options are most reasonable?
• Do not scope the stomach now as the patient is still sedated from the colonoscopy and cannot give consent. Once the patient has awakened and recovered, discuss the new diagnostic hypothesis and obtain informed consent to examine the stomach to look for a bleeding site.
• Forge ahead with the stomach scope exam while the patient is still sedated. Assume informed consent and proceed.

I opted for the latter option. Ethically, I felt that I was on terra firma as the patient had already consented to a colon exam to evaluate the bleeding. It seemed absurd that he would have consented for a colonoscopy but withhold consent for a stomach exam that was now deemed essential to pursue the same diagnostic mission. Moreover, the patient had received multiple transfusions so there was clearly a medical urgency to identify the bleeding site.

Assuming consent for a subsequent procedure that was not initially anticipated is rational and defensible if the test is clearly in parallel with the medical evaluation and there is a medical exigency present. Presuming informed consent, however, is an exceptional event. Physicians are not permitted to go rogue.

The blood in the colon didn't come from the colon, as I had wrongly suspected. It came from a duodenal ulcer just beyond the stomach, which I easily spotted with the stomach scope exam.

This patient didn't go by the book. Sometimes, we physicians need to deviate from established policies also.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.