ACP Internist Blog

Monday, October 14, 2019

The Emperor's healthy climate

As I write this, children around the world by the millions are poised to skip school to protest our avarice, delusion, myopia, and irresponsibility, and demand action on climate change. As children speak their truth to the colossal failures of our power, we might all constructively recall that we were children once.

When we were, our education included parables, fables, and fairytales. Among these, inevitably, was The Emperor's New Clothes among other folk tales by Hans Christian Andersen.

No doubt, you recall the gist. A leader with all the wrong concerns and priorities is duped by those with all the wrong motivations into denying the obvious. Adults all go along with the delusion for fear of embarrassment, cost, or retribution. Children point out the obvious: the emperor has no clothes. And then the scheme of the wicked weavers and the many versions of corruption and cowardice by proxy unravel for all to see. Children reveal the truth glaringly on display in plain sight that the grown-ups are all complicit in denying.

We have cause to ask ourselves now if we are even one step more ridiculous, and contemptible, than these fairytale culprits. Will we persist in denial even after the children call us out?

I realize, inevitably, this sermon is reaching members of the choir in many instances. But obviously not all, or climate change denial would not be feasible. Obviously not all, or opposition to the children's plea for a viable planet could not populate the halls of power.

Accordingly, those of you robustly on the side of today's children already are invited to say “amen!” and go about your business. Those of you worried about what seemed to be on display- weird weather, dying trees, melting glaciers, flooding rivers, disappearing birds and bees and butterflies- but nonetheless in doubt because of the alleged doubts of others, be assured. The truth is as obvious as it seems through the unclouded eyes and uncluttered motives of the children.

The naïveté of folk tales and fables was never that their messages were wrong or in question. The naïveté was always, and only, that their messages were right, and so obviously so that they needed to be veiled to protect the innocence of children. We might all have been told, directly, that adults were insecure, sycophantic social climbers so eager to fit in and conform that they would deny the truth on naked display. The folk tale allowed us to hide our own deficiencies behind the fictional characters, and break the news to our children rather more gently.

Still, here we are, ignoring all around us a lesson so obvious and unequivocally true as to be quaint in its folk tale incarnation.

Folks, the Emperor has no healthy climate; the Emperor has no healthy planet. And yes, of course, everybody already knows it.

Lest you think, even for an instant, that true or otherwise this should be a concern expressed elsewhere, climate change and planetary degradation are the signature imperatives of my profession at this time. There is a reason for the burgeoning field of planetary health. There is a reason why major medical journals are spinning off derivative publications devoted to environmental issues. There is a reason for conjoining the fates of people and planet, and situating them on the same menu of options. There will be no healthy people on an uninhabitable planet. There will be fewer and fewer healthy people at each step of the unpleasant journey toward such ruin.

Climate change is a medical issue. Climate change is a public health concern. Preventing further degradation of our forests and aquifers, oceans and atmosphere, fauna and flora is the one preventive medicine opportunity to rule them all. The years in life and life in years to which I have pledged my career and devoted my effort these past 30 years are entirely subordinate to the fate of Earth.

While merchants and minions of doubt have worked their mischief for costly, and perhaps utterly calamitous decades, the children are quite correct: climate change and our implication in it are every bit as obvious as the Emperor's epidermis. We have known without doubt for decades what greenhouse gases tend to do. We have known without doubt for decades that we were putting unprecedented and ever more quantities of just such gases into our atmosphere.

We did not know exactly what the planet's tolerances would be. We did not know just when the crucial breaking points would arrive. We did not know exactly how complex ecosystems would resist or collapse, or how cascading effects might forestall or amplify climate change.

All of these, therefore, needed to be modeled by scientists. As the merchants and minions of doubt were always quick to point out, such models are ineluctably imperfect and may at times be substantially wrong. What they never pointed out was that they could be wrong in either direction. Climate scientists have never denied the imperfections of their models. There is a fast-growing consensus now, as melting permafrost releases methane that speeds the melting, that the models were indeed wrong by being too optimistic.

Neither you, nor I, nor our children, nor any emperor has a planet impervious to our depredations. None of us has a healthy climate or a guaranteed future.

The children are merely giving us all permission to admit the obvious, and then act like the world depends on it.

David L. Katz, MD, FACP, MPH is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his Linked In page.
Friday, October 11, 2019

The doctor walked straight past and didn't even acknowledge us

One aspect of medicine that anyone who reads my work knows I'm most passionate about is keeping excellent communication at the core of health care. It's a vastly under taught skill, and although medical schools are certainly getting a lot better at teaching the fundamentals than they were a few years ago, there's still nowhere enough reinforcement throughout ones medical career. It's therefore easy for all of us to slip into bad habits. Don't get me wrong, physicians do a difficult job, and it's probably only a tiny minority that are really bad communicators. However, each one of us (yes, everyone) can always do with constant reminders and be on a learning curve to make ourselves better.

I'm going to relate one story in particular that happened to me not so long ago. I was back in England and my mom had been scheduled for an elective surgery. I made sure that I would be home for it (thankfully it wasn't anything major) and the whole family went into the hospital in the morning. We spoke to the surgeon and he went through the procedure and took consent. He told us the surgery would be later in the day. So we waited. And then the afternoon came and we continued to wait. 2 o’clock. 3 o’clock. 4 o’clock. No word, and my mom was not eating (NPO). We asked a couple of times if there was any news about the timing, and the nurses just apologized to us and said they would let us know as soon as they heard something from the OR (in England we call it an “Operating Theatre”).

Finally close to 5 o’clock the surgeon came through the waiting room and went to speak with the charge nurse. He then strolled straight past us, all of 10 feet away, gave us a glance as we stared at him, and just carried on. The charge nurse came out and said that unfortunately due to some staffing issues, the OR was closing, and they couldn't do the surgery on that day. She expressed a genuine apology, but we were of course very disappointed (this was the NHS, with its long wait lists, and the surgery ended up being delayed for over a month). Anyway, what actually disappointed us the most—more so my mom—was the behavior of the surgeon. My mom's life would be in his hands and we had placed our trust in him. Yet he walked past several times during the day and finally at the end he traversed us without even acknowledging us, despite knowing full well we had been waiting the whole day.

I wasn't really as upset as my mom (I'm really not easily offended, and know how busy health care is), but more just shook my head because I know slights like this happen every day in medicine, even on this side of the Atlantic. How much effort would it have taken for that surgeon to stop, turn around, say sorry (for factors which were probably beyond his control) and at least respectfully acknowledge my mom? Probably all of 20 seconds. Even within a socialized National Healthcare Service, with much less of a customer service mentality than the USA, it's still the respectful thing to do. Whether health care professionals like it or not, we are held to a higher standard of courtesy by the general public than the plumber or grocery cashier.

One of the most frequent requests that is thrown any physician's way during our long and hectic work days is: “The patient has a few questions” or “The patient's family is here and would like to speak with you.” I know that for lots of doctors, this can be perceived as something of a drag, causing an instant rolling of their eyes. Certainly we may occasionally have a few difficult patients and families, but the majority of the time this isn't the case. Every physician should actually see these requests as a natural part of the job, and not anything extra. Because it's the part of the job that is truly remembered and leaves a lasting mark. It's not about clicking boxes on a computer, ordering and reviewing tests, meeting targets, or writing medical notes. That's the extra part. All doctors should see themselves as the “Communicator-in-Chief” and the face of medical care, not just the physician-scientist. No matter how suboptimal our health care system, bloated our administration, or how behind with time we feel— nothing comes before communicating with our patients. Imagine yourself in that position of feeling vulnerable, or sitting at the beside of the person you love most in the world. How much you'd appreciate that good communication.

So if you're a doctor, do not underestimate the power of just having a minute of extra conversation with a patient and family member. Stick your head in a room as you walk past, stand there for 20 seconds and ask if everything's okay. When you see a family all sitting in a room, go in, say hello and introduce yourself as the doctor in charge. These little sincere things can blow your patients' and families' minds away, because it's still so rare, and will instantly put you ahead of 95% of other doctors in their minds.

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.
Monday, October 7, 2019

Do patients like weekend and after hours medical care?

I have previously expressed how physicians feel about treating patients that they do not know in a prior post, which readers are invited to review. This post is the other side of the story.

Nowadays, patients are used to seeing physicians who are not their doctors. Often, patients may be seeing a nurse practitioner, a highly trained professional for their medical care, instead of a physician. A generation ago, patients nearly always saw their own physician, including if a patient was hospitalized. Imagine that, your own primary care doctor sees you in the hospital, an event that occurred when dinosaurs roamed freely.

The medical universe has changed. Hospitalists care for most hospitalized patients, which in my view, has vastly improved the quality of hospital medical care. It is commonplace for patients who need to be seen right away in the office, to see a doctor who is available, who may not be the physician of record. Pregnant women today often see many obstetricians in the group since it is unlikely that the patient's designated obstetrician will be on-call on D-day. One of Cleveland's corporate medical giants boasts that they offer “same day appointments,” which is true if a patient is willing to see a medical professional several ZIP codes away, not the patient's actual doctor.

Understandably, if you call your physician after hours or on the weekend, you will most likely connect with one of your doctor's partners. This is why it is not advisable to call the emergency on-call physician 9 p.m. for a conversation about your chronic arthritis.

Patients are now used to seeing strangers prescribing their medications and ordering their diagnostic tests. Hospitalized patients may be treated by several physicians they do not know. They have adjusted as best they can, but there are obstacles and drawbacks to this medical care paradigm.
• It is unsettling for patients to be confronting several medical professionals for their care. Similarly, if you are reading four or five books at once, are you really able to keep the separate stories straight in your mind?
• There is unavoidable loss of continuity when there are multiple physicians at the table. Hospitalists do a great job. But, do we really think that all of the nuanced knowledge and objective data can be seamlessly transmitted to your primary care physician whom you will see after you are discharged?
• What if different primary care physicians who are seeing the same patient have different opinions? Who does the patient believe?
• Even in the computerized era, it's astonishing how often new physicians do not have easy access other physician's medical records. Does the weekend physician consultant who is seeing you in the hospital know that another doctor already ordered an ultrasound of the gallbladder a few months ago across town?
• When there are too many physicians involved in a single patient's care, medical testing and costs tend to increase, which does not increase medical quality. In my experience, a new doctor is more inclined to order a medical test, than to advise watchful waiting, a strategy that the doctor who knows the patient well would more likely rely on. For example, if I see a patient I know for years with the same stomach pain, I may react differently than another gastroenterologist seeing him for the first time.

Oftentimes, patients and physicians meet as strangers. This reality creates many challenges. Both sides need to be understanding.

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, October 4, 2019

The tough and no-nonsense teacher of medicine that we should all want

The best teacher of medicine I ever had was during my medical residency. He was a tough old-school physician, trained at one of the premier institutions in the country, and specialized in pulmonology and intensive care. Before I had even rotated through the ICU, I had seen him around on the medical floors—and must admit I didn't like him very much at first. He seemed extremely serious, not particularly friendly to any staff around him, and was very strict about what was happening with any of his patients—always wanting things done in a certain way. He wasn't overtly rude, just not a “warm and fuzzy type” in any shape or form. A co-resident told me that he was a great physician, and despite any lack in social skills, was “the doctor I would always want caring for any sick relative of mine.”

My ICU rotations started mid-way through my intern year (this was back in the day when we still did grueling 30-hour calls, often every 3 days). Having him as my attending though, quickly changed any negative perceptions I may have prematurely had. Quite simply, he was an absolutely brilliant doctor, who knew just about everything there was to know about critical care. He could quote any major paper or research study from the last decade, and remembered every little detail about each one of his patients, who actually really liked and respected him (he always communicated surprisingly well with patients and their families).

Teaching-wise, he was completely no-nonsense, and always had us on our toes. We made sure we had everything right before we presented to him, and he would tear us to shreds if we stuffed up on any important issue. We looked forward to his inevitable rapid-fire questions and read around every disease that we were dealing with. He was a tough, tough boss—but without question the outstanding teacher whom we all wished to learn from. If you wanted to be treated nice or molly coddled, he was not the one. He would evaluate us and be brutally honest about any areas we fell short.

At the end of my residency, I stayed behind for an extra week unpaid, just to rotate with him one more time and learn whatever I could. I'll never forget that during that last week, he pointed to two rooms that had patients of similar age and medical histories. They had both been admitted the day before with a similar degree of pneumonia. One was sedated on a ventilator, and the other was sitting up, looking well, and ready to leave the ICU. He said something along the lines of: “Look at that, such similar people and such different responses to the same illness. I predict that during your career the biggest breakthrough will be in the field of genetics. We'll be able to do a saliva test and predict exactly how people will respond to any illness.” I wouldn't bet against that coming sooner than we think.

As I shook hands with him on my last day and said goodbye before embarking on life as an attending physician, he paid me one the best compliments of my residency: “Call me when you're Chief of Medicine very soon.” Although that didn't end up being my chosen career path, I was delighted that a man of his distinction said that to me, and it gave me quite a boost.

He remains my favorite teacher, as I know he has been for many others too. He won an array of teaching awards and accolades. My fear however, is that we are fast losing mentors like him in our modern culture of learning. Teachers like him are becoming a dying breed because a very different sort of teaching environment is now being encouraged. In fact, we are rapidly approaching a point where an attending like him would be frowned upon. I'm sure though, if you honestly ask most medical students, interns and residents—they would rather be taught by a tough attending like him any day. The current trend (and this applies everywhere, not just medicine) is for teachers to be more like their students “friend.” I believe this is a big mistake. From talking to some of the younger teachers of medicine at some of our larger academic institutions, I even get the feeling that many of them are almost afraid of getting negative evaluations from their students, so want to please them as much as possible. Again, another big mistake and paradigm shift. I can assure you that if there's one thing the doctor above didn't care about, it's what his students thought about him or trying to be their best friend.

When I was a medical student in the United Kingdom, I also came through the system at a time when I got to work with some proper old-school professors. Some of them, if they ever saw the male medical students slouching when we were walking around together on rounds, or folding our arms casually, would physically grab our back and shoulders and tell us to stand up straight! At the time none of us minded whatsoever (we actually found it funny). I am not suggesting a return to military-style academics, or allowing any inappropriately strict or condescending behavior, but I hope in this new era, we can balance the need for a more gentle approach–with that more traditional respected tough teacher approach—that any student worth their salt secretly likes and craves. I hope future generation learners of medicine, or any profession, always have a chance to be taught by someone like my ICU attending.

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.