Rules and Regulations: Is Cover-Your-Ass Medicine Devaluing Healthcare?

Today was the day I realized I will have to go into family medicine. Not because I loathe internal medicine (quite the opposite--I have loved almost every day of this clerkship) but because I cannot work inside a hospital. There are many terrible things about hospitals. They are full of sick people. And because they are full of sick people they are always full of the things that accompany sick people in societies both full of resources and those that reside in the third world: the smell of disinfectant mixed with the odor of bodily excrement--almost unavoidable if you spend a day walking around on the floors; the screams... the tortured moans of patient's suffering either from a psychiatric issue (although who wouldn't be driven insane by being locked up in a hospital room for days?) or a pressing physical complaint? (I don't imagine a leg ulcer infested with maggots* can be purified without any amount of pain).

But, unfortunately... well, unfortunate for those people who find themselves confined to hospitals, and also for those people like me who have the option of working in one... the worst thing about hospitals isn't the patients or their illnesses. The worst thing about hospitals are their dumb-@$% rules.

I have a patient. He is my only patient. He is my favorite patient. He is super old and he has borderline dementia.... he reminds me of my father and so I try to be super nice to him because he, like my father in about a decade, deserves the best.

One of the things that is really hard to deal with while working as a pretend internist is how old and close to death so many of our patients are. In surgery, all of our patients had to be surgical candidates, and to be a surgical candidate you have to be able to withstand general anesthesia and someone poking around your insides. This is not so with internal medicine. Hell... one of our team's patients died the other day.

SIDE NOTE: I think surgeon's fear death way more than other physicians. While m&m's (morbidity and mortality) presentations for internal medicine (IM) are relatively tame and emotionally controlled, surgery m&m's seem to be intensely discussed, with the accusations of "who-to-blame" are hotly debated. I think this is a result of surgeon's wanting to, one some level, think of themselves as able to prevent death in their patients. I think this also makes much more timid, surprisingly, when it comes to patient care. I called both of my parents today (remember: both of my parents are surgeons) to ask them what they would have done with one of our patients: patient is an 84 year old man, with a past medical history significant for hypertension, diabetes, and two previous strokes, who was admitted to the hospital 7 days ago with slurred speech and left sided facial weakness suggestive of acute, focal cerebral ischemia, with brain CT and MRI also suggesting stroke, who know, the day before being cleared for discharge, has spiked a WBC count. Both of my parents said he should stay in the hospital. True, you should find the source of his infection. But we could almost be sure what the infection was... couldn't we just treat him for that and send him on his way? The extra care my parents seemed willing to offer might have simply been an artifact from how much more surgeons have to pay in medical malpractice. OR, they could simply hate seeing patients die from something so insidious and so simple as an infection. 

Where was I...? Yes, the incredibly stupid rules. And I'm not complaining about stupid seeming rules that are set up for the purpose of patient safety. For example, this patient, with his borderline dementia, was put on high fall precautions... essentially, he was strapped to his bed by soft handcuffs, which are called "soft restraints" in medical jargon. I understand this rule--if he falls out of bed he could easily die--although it is terrifying to think of fading in and out of orientation to a world in which you are permanently tied up against your will. No. I hate rules like the one that requires the next of kin to physically enter the hospital to sign cover-your-ass paperwork when the patient isn't at full decisional capacity. And even though a lot of terrible malpractice cases, a lot of morbidity, and a lot of mortality have arisen from the fact that things weren't explained well enough to the patient, there are some procedures that are so non-lethal it really doesn't make sense to require the patient's family member(s) to come in. Some people are busy. Most people are busy. Even I never get a weekday off work... if I was told I had to go to the hospital on a Wednesday to fill something out so that my parents could get discharged... I'd probably still take until the weekend to scrounge up enough time to liberate my parents. Doctors know what's best for the patient. We shouldn't have to explain to the patient how the procedure is done, what risks are involved... if the risks are minimal enough.

I know, I know: that wreaks of paternalism. But in all honesty, what we do now is highly inefficient. If I become an internal medicine resident, I'm going to spend my intern year writing down all the times money and/or time was wasted because we had to get paperwork down before patients could get what they needed and leave the hospital as soon as possible. Some patients love staying in the hospital... most patients don't. All doctors want to see their patients get back to baseline so that they can be discharged. But I don't think enough doctors want to put in the time necessary for analyzing why these rules and regulations are often detrimental.

Or maybe we just don't have the time. After all, I rarely see doctors taking off weekdays.

*yes. there were actual maggots in this patient's room. there were actual maggots under her skin. however, when they were finally discovered and the wound care nurse and her assistants were telling everyone outside the room about their findings within, I did not--in that moment--have enough courage to walk inside and look that hollering woman in her face while examining her wounds. I was not brave enough to examine and deduce what exact parts of her scabbed up wounds were flesh and blood and what were maggots.

So this is emergent care?

My teammate and I were sitting on the plethora of abandoned chairs in the emergency room. It was an odd time of the day for people to show up--right around lunch time--and it wasn't the right weather: too cold to be outside and accidentally or intentionally get hurt. Yet there were still patients in about half of the rooms, and because we were on call, all those patients who could be deemed fit for admission had to be processed by us. While we had been interviewing a man with suprapubic pain suspicious for bladder cancer, nearly continuous screams were emanating from a female patient nearby, drowning out the sounds of televisions, beeping monitors, and phone calls. I've been getting better and better at ignoring people screaming in hospitals. But this woman was loud and persistent and every once in a while I could hear the crashing of equipment or cheap furniture, and I'd wonder why a code hadn't been called yet or why nobody had tried to administer drugs.

I was incredibly saddened that the screaming had stopped--it is secretly my dream to rush in to help with a "Paging Dr. Strong" or "Code Grey" (combative patient/person). Alas, today was not going to be that day. Our intern had disappeared again so we had little to do except periodically check up on our patients through their electronic medical records. And then... an Emergency Medicine resident swept by and without hardly stopping asked: "You medical students?" "Yea," we both answered. "I need one of you to follow me." I started asking why as my friend was already standing up to follow him--she is way more instinctively helpful than I am. "To chaperone." Only as they were entering one of the private rooms did I kind of understand. Female patient. Delicate issues. Male doctors needed a female in the room. How obnoxious and unnecessary. So this is where politically correctness was taking us, that male doctors were no longer trusted enough to perform gyne check-ups without female supervision. 

Shortly thereafter, I was pulled away by one of the resident's on my internal medicine team to help out with ABG draws and paper work and phone calls. Eventually my teammate pages me.

"Hi Elora. It's Rebecca. Where are you?"

"The residence room. Why?"

"Okay. I need to tell you something. Will you be in the residence room for long?"

I looked at my computer screen, at the list of patients who were awaiting results of labs and imaging.

"Yea I'll be here."

to be continued. 

Internal Medicine Clerkship (Entry 1: First Impression)

So now I'm starting the third week of my internal medicine rotation, and I am loving it. These residents are significantly nicer than the surgery ones (although most of the surgery residents were definitely good human beings), and because of that, I feel like I'm getting more out of the rotation. Basically, I feel forced to learn and study on my own because not looking something up would make my residents disappointed in me and that would break my heart.
Speaking of hearts, and as an example of the previous statement made above, I finally understand EKGs. It's still very difficult for me to determine what the exact diagnosis is, but considering before I could only get rate, I think it's a step in the right direction. Maybe by the end of this rotation I'll feel and sound intelligent! The only drawback--but it's not that bad--is there's a lot of scut work. A lot of using pagers and calling people and talking to nurses, or social workers, or consultation services.
Speaking of scut work, today I was trying to decipher a note, but it was using an abbreviation I didn't know so I sent an e-mail to my surgeon dad to see if he knew what it was (I could of more easily used dr. google, but I like to keep my dad informed of my learning).

ELORA: "Hey dad! Does PCI stand for percutaneous catheter intervention? Thanks!"
FATHER: "I am not sure. That is why acronyms are not welcome in medical practice. It does make sense that PCI stands for percutaneous catheter insertion. It could also stand for pulmonary catheter insertion or pulsatile cardiac imaging. The message is TRY NOT TO USE ACRONYMS unless you are with friends, who cannot judge you. Dad."