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.

Compliance & Threats

Currently I am in Clinical Neuroscience. We are being lectured to about sleep disorders, specifically sleep apnea. The guest lecturer appears to be in the range of 40-60 years of age.

Concerning sleep apnea, there is a fairly successful treatment: continuous positive airway therapy (CPAP). Unfortunately, compliance with CPAP is pretty low. Only 46% of patients use the therapy, and of these persons, only 70% use it on a regular basis.

The lecturer urged us to tell our patients: "You're going to die in the most horrific way imaginable then list all the complications of uncontrolled sleep apnea."

This was one of my major complaints for my previous endocrinologist: vague threats. I can understand why doctors would want to do this--it is really frustrating when you're trying to help someone when they're not trying to help themselves. But I wonder if there isn't a better way to tell someone that they're killing themselves. Would this involve asking them about their life goals and how non-compliance will negatively affect these goals? I think it does.

Regardless,

I suppose doctors are among the few people that can tell you--in disturbing and exact details--how you're going to die without you freaking out and calling the cops.

The Human Model

You can learn a lot from patients.

Sometime last week I went over to the Hospital of Veteran's Affairs to volunteer at a clinic. The clinic is submerged into the homeless shelter at the VA. We were instructed to take patient's histories, a skill we all learned as part of our Essentials of Clinical Reasoning course. I was uncomfortable at first, but it's always surprising how human-like human patients can be.

Regardless, one of the people I saw was a fellow diabetic. While the people running the show scrambled around looking for an appropriate test meter (because I do not know how to use the really fancy ones; OneTouch meter's are always full of extraneous options that I can't work), I got to talk to the patient.

Somehow we got onto the topic of significant others, and the diabetic had some wise words to say about the ills of domestic violence. He said two really touching things. The first was a rather hilarious anecdote about the only time he had hit a girl. It was in high school, and he had slapped his girlfriend, thinking to himself that she was acting like a b*#$!. Well, he had not been counting on being held accountable. Coming home, he was greeted by his seven sisters and his affronted girlfriend. They did more than "explain" why his behavior was out of line.

Second thing: he expounded on why women are ultimately the more important gender. I was fairly impressed, and I keep thinking about what a character that diabetic was. I want to write more about him, or at the very least, write down what he said so I can tell my own kids how to avoid domestic violence in relationships. Honestly, I don't think he learned anything from me. But I ended up learning a lot from him.

Another strike against paternalism. Perhaps the doctor-patient relationship is more like a symbiotic relationship, where both groups are made better through their interaction. Regardless, I feel like I could write a chapter on the character that this patient presented, even if briefly--even if less than twenty-minutes.

This is why I went into medicine.

I want to learn more about the human condition. I can't write about people if I do not understand them, first. Certainly that's not only the reason I am in medical school. But for the part of me that is a writer, that's all the motivation I need.

How Doctors Think

In anticipation for orientation, I've been reading How Doctors Think by Jerome Groopman, MD. It was interesting, and I was immediately compelled to finish the 200+ page book after he references and quotes Judith Hall and Debra Roter in the introduction. Hall and Roter are two researchers who have looked extensively at doctor-patient interaction and communication styles, and I referenced them a lot in my Rhetoric thesis that examined communication in health care. The book was eye opening in that it did a great job of informing the reader about which types of cognitive errors bias the way doctors treat their patients. Absolutely fascinating. I've always found that understanding logical fallacies allows you to deal with people and to make sense of complicated situations. To know that there are several logical fallacies that even well intentioned doctors make frequently is reason enough to write an entire book.


I have two concerns with Dr. Groopman, however. First, he seems to be praising all the doctors he talks about (with a few exceptions). I wonder if it would be more useful for people to know how bad doctors think more so than to understand how competent doctors deal with diagnoses, because sometimes you aren't given the liberty, although you should have it, to choose your clinician for yourself.

My second concern is more insidious and/or uppity. Paternalism. It's clear that Dr. Groopman is against it. He is quick to praise a few doctors who unbiasedly talk to their patients in order to make sure that their patients choose their treatment for themselves and aren't subjected to being helpless to control their own medical destiny. But Dr. Groopman has a severe pronoun problem. Even though he talks about two or three excellent female physicians, he always refers to doctors as hes. And I guess that wouldn't be unforgivable, because grammatically he can be used as a gender neutral pronoun, even though it no longer carries that meaning for most readers. No, what makes it unforgivable is that he often refers to hypothetical patients as shes. He even ends his book talking about this hypothetical patient, and how she is adding vigor to the clearly sexist clinic by being an expert communicator and able to understand her male physician's every thought.

Gross. When the movement began to minimize paternalism in the clinic beginning in the 1970s, paternalism was symbolized by the interactions women had with men in that time. Women don't make decisions. They let their husbands decide for them. Because men and doctors generally have an elevated standing in society compared to women and patients respectively, this visualization makes sense and should strengthen a progressive individual's will to end clinical paternalism at all costs.

Though the insight that Groopman has into clinical practice makes it easy to forgive him. Also, the fact that he's in his sixties or seventies and trained during a much more... sexist time, makes it a burden, but an acceptable one, to not get overly upset and just take value where there is some and ignore the rest.

Debra Roter and Judith Hall are two excellent female researchers. They have looked into the differences in communication styles between male and female physicians and are aware of the challenges facing women in health care. I wonder if they, after reading Groopman's book, noticed this slight rhetorical misdeed, or just conceded that there are some minor injustices you just have to accept.