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Wednesday, March 5, 2014

Sick patients with chronic diseases and the wisdom of Dr. Bernard Lown

I have been doing admitting shifts at a large hospital, as hospitalist. It is flu season, so volumes are large. Even people without the flu are sick. It often happens that way. And they are so very sick!

The thing about the very sick patients I see is that they are generally what might be called “medical train wrecks.” They are very sick because they have had interventions over the years that have caused them to be dependent on more medical interventions. In some cases this means that they are alive when they would be dead otherwise, and in some cases medicine has allowed them to make more terrible choices in their lives and be subsequently more miserable than they would have been if forced to face the logical consequences of their behaviors. Often these 2 stories are played out in the same people. It is hard to take care of these people because they have had so much done to them, have taken so many medications, had so many complications that the landscape of caring for them is like a mine field.

I saw a former smoker whose lung disease was so severe that he couldn’t stay out of the hospital for more than a week, and lived at a nursing home. His disease process had progressed to the point that he no longer was able to breathe off the carbon dioxide in his system and when this would build up he would become more sleepy and breathe even less. He also was prescribed strong opiate pain medications for his back and neck pain, worse because he stayed in bed all day and struggled to breathe, but which made him sleepy enough to not move or cough or breathe adequately. He was aware of how this worked, but unable to imagine life without pain medications for his numerous aches. He had been discharged from the hospital only a week before, on intravenous antibiotics through his nursing home which he was still getting when he returned. I suspect he had been on antibiotics for much of the last year, and these were the ones designed for resistant bacteria, which he probably harbored. I was probably the 100th doctor who had seen him and it was unclear what intervention I could make that would improve things at all.

I saw 2 people who were immigrants from very poor countries, but had been in the U.S. for decades. Neither of them could tell me about the medical history of their parents because their parents had never seen doctors. Both had end-stage renal failure. One had received a kidney transplant after 8 years of dialysis, certainly well over a million dollars of medical costs in 10 years. The U.S. takes special care of patients whose kidneys have failed, usually finding money to pay for their expenses either from Medicare or Medicaid funds, or often both. The patient’s own funds are almost always completely sapped as well, but no individual can afford long term kidney replacement therapy, which can run thousands of dollars a week, even without the decompensations that are so common in such patients. These were interesting people, but they had suffered physical pain as well as the shame of uselessness and dependence as America’s often generous and certainly technological medical system kept them alive.

It may not sound like it, but I do respect these people and enjoy the opportunity to work with them. I also feel conflicting loyalties, because these, my patients, are part of a dynamic that wrecks opportunities for other people to stay healthy and alive. I just read an article from the USNews describing how health care costs, specifically insurance for city employees in this case, resulted in a community budget that couldn’t afford after school programs and struggled to support even minimal recreation programs. School kids collected thousands of pounds of old shoes to raise $6000 to save their after school activities. It is the work of an hour to spend $6,000 in health care.

Many of the patients who find themselves in these dependent relationships with the medical profession are poor or old or otherwise disadvantaged, leaving them less able to make decisions about their lives and less able to advocate for their own wishes with healthcare providers. They are carried along in the flow of “This is what we do with people with your condition.” Once saved by medicine, it is very difficult to take a different course.

I was feeling kind of sad about all of this when I found something in my email that cheered me up.

Unsolicited, in my primary inbox, was a letter from the Lown Institute. In the e-mail they linked the article I mentioned a few paragraphs up about the school kids who had to raise money for after school programs because their community spent so much money on health care. I went to their website and was surprised to see that the group is full of super high functioning people interested in health, mostly doctors but also public health people and even the founder of the Panera Bread Company.

Per their website “We seek to create and foster a new social contract between the profession of medicine, the business of healthcare, and civil society.” What this appears to mean is that they are working with powerful people to move medicine in the direction of providing thoughtful and considerate care for the human beings who are our patients. The founder, Dr. Bernard Lown, is originally from Lithuania and practiced all of his life in the U.S. He invented the defibrillator, which has saved countless lives of patients who lose circulation suddenly because of a heart arrhythmia. He also won the Nobel Prize for starting the physicians group that became Physicians for Social Responsibility, which advocated against nuclear weapons. He is a well-spoken advocate for really good medical care, meaning listening to patients, examining them and not doing stupid and harmful excessive testing or treatment. I would happily sit at his feet. He continues, in his 90s, to advocate for the right stuff, and I could probably simply link to his article, which is beautifully steeped in over half a century of being a doctor and now a patient, rather than writing anything at all.

It is heartening for me to see that there are good, kind people with excellent minds who are outspoken and influential at the highest levels of discussion. People like Dr. Lown remind us to be doctors rather than highly educated data managers and test orderers.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, 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.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, 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.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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