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Monday, May 16, 2016

The dog in the fight

I came on as the attending on a Monday. An unexpected scheduling need had shifted my assignment from the outpatient clinic to the inpatient hospital service. By the time I joined the team, the month was nearly over and plans were mostly gelled. Consultants were following and things were rolling along as they often do. And during this week, the census was full and the patients were sick. Very sick.

Okay, so I come onto the scene as the Monday morning quarterback, literally. A new set of eyes who is looking at every case from the 30,000-foot view, first seeing the big picture and then trying to serially zoom in on the little picture parts. And this, this approach when I come into something where the ball is already in motion, is generally my approach. I observe and ask some questions. I make up my mind to be a skeptic and to not just go with what's already happening. Even though, most of the time, I am completely in agreement with the current plan.

Yup.

But sometimes when stepping in something happens. You realize that everyone involved has been so zoomed in that they've lost sight of that big picture. So you come strolling up and start firing off all your queries. They seem like obvious questions, actually. I know this because I've been there. The one who has been slugging it out for weeks on a sick patient only to have someone ask 1 or 2 things that make me wonder what the hell I've been doing all this time. That, or they point some very clear observation out that makes you inwardly cringe because it's the kind of thing you should have asked yourself a full week before.

Anyways. On Monday, that's where I was. And there was this one patient in particular that didn't seem to make perfect sense to me. I mean, it wasn't because the last attending wasn't awesome. It was more one of those things where the Monday morning quarterback had the advantage, you know?

So yeah. I look and I ask and I probe. And finally I resolve that we needed to shake up the game plan some. And by shake it up, I mostly meant that we needed to go harder as advocates.

Yes, that. Advocates.

So what does that mean? Well. To me, it's simple. What I do is close my eyes and picture myself as the very concerned mama-sister-wife-daughter-granddaughter-partner at the bedside. I push myself to let the patient matter to me as it would to that person. I pop in my mouth piece and shadow box in the corner. And then I go as hard as I can, as if that person's loved one is strapped on my back pleading with me to help.

Does that sound crazy? I know it probably does.

Okay, so let me explain what was going on without giving too much detail. Essentially, a lot of doctors were seeing this patient and weren't in full agreement. One said to do 1 thing which would require another one to do a procedure. But the procedure-doing doctor didn't feel so much like that was needed. Then, another consultant was somewhere in the middle. Maybe a procedure, maybe just more antibiotics. But see, for me? The main thing I saw was a patient who, despite all that, was still sick as stink. Which meant somebody somewhere was going to have to do something different than what we'd been doing.

Yeah.

And so. I strapped them to my back. The patient and the ones who love my patient the most. I fought with the zeal of a mama bear protecting her cubs. Called and spoke to attendings directly and asked some uncomfortable questions. Pushed my colleagues to be decisive and to also feel the sweet burden of caring like it is their loved one, too. And what I've found is that I work with some good, good people. These good, good people are very busy and often spread thin. But since they are good, good they are usually willing to slow down long enough to stick a foot in the way of the clinical inertia ball.

We all talked. And thought. Together. Someone pulled papers from the literature and others modified recommendations. The senior radiologists did more than just read the images; they re-read them with their experience in mind and the clinical context considered. And all of it felt right and good.

So what happened? Well. Slowly but surely, the patient started improving. But mostly, it felt more like we were on the same team, you know? Instead of just a bunch of stakeholders with our own prideful opinions, we were one big, bad team. Fighting the hell out of that disease and telling it that we weren't the ones to be effed with. Knowing that not only do we have a dog in the fight, we ARE the dog in the fight.

Yes. That.

And you know? It's not guaranteed that any of this will work. The patient could remain ill regardless of our earnest attempts and reroutes. But I like to remember 1 of Harry's quotes about losing a fight:

“I might not have won, but he knew I was there and I'm pretty sure he'd never want to fight me again.”

Ha.

Let me be clear: I am just as guilty as anyone else when it comes to all of this. I fall in love with a diagnosis or plan of care that I developed and can't see the forest for the trees. I also forget that my fifteen years at Grady has afforded me a voice that someone might listen to and entertain if I ask questions. I'm guilty of sometimes letting my exhaustion dampen my enthusiasm. Totally.

But then, like clockwork, in comes a Monday morning quarterback. A good, good colleague nudges me to do the right thing. To reexamine things with fresh eyes and to fight like my loved one depends upon it.

Does any of this even make sense? Probably not.

My point is this: There is a lot of stuff that just can't be learned in books. And this? This little shift in how we see ourselves as patient advocates is just one of them. I'm still learning. But 1 thing I can say for sure is this: I'm still trying, too.

Yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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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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