Doctor/Nurse Communication: The System Breaks Down…Old Fashoioned Medicine Prevails!

 

 

 

“The diagnostic team that treated Duncan — who had symptoms of headache, abdominal pain and fever consistent with the Ebola virus — did not know he told a receiving nurse that he had traveled from Africa. On that day, Duncan was sent home with antibiotics. He returned to the hospital by ambulance two days later.”

 

http://www.latimes.com/nation/nationnow/la-na-ebola-hospital-20141003-story.html

 

As the Ebola virus continues to make world news, I am struck that one important aspect of this story is not getting enough press. The nurse got the history of possible Ebola exposure, but the doctor did not. Nor did the nurse adequately communicate this VITAL piece of information to the doctor. This viral scare, from my point of view, highlights the prime importance, once enforced in medical training, and now less so, that a doctor MUST always take his/her own history. The idea of relying on other professionals for a history of present illness, as in this tragic case of Thomas Duncan, can cause fatal mistakes, History taking is/was the foundation of good medical care. This was the most important thing I learned in medical school, in rotation after rotation. Yet, today, there is a notion that professionals should work to the highest aspect of their license, meaning that one does not need an MD to take a history. Physicians are needed to prescribe, to order tests, but not to get background information. This background can be obtained by medical assistants and nurse practitioners.

Oh, no no, I say, learning of this paradigm change in health care delivery. With all due respect to nurses, there is the art to history taking with leads to accurate diagnosis and treatment. My professors, rightly, and repeatedly, taught me this. 80% of the diagnostic information is from the history, they would say, which became the often mocked mantra. Yet, almost thirty years later, those words come painfully alive, as we discover that the doctor did not do a “travel history” on Mr. Duncan. This pertinent omission of the history has sent this country into anxiety, reaching near panic levels in some. The focus has been on politics, on travel bans, on protective gear training, and yet, where are the doctors yelling about the need to reinstitute history taking as the vital art in medicine? Yes,in  most cases, the history is less critical and symptoms can point the physician in the right direction. However, once in a while, a critical case will come in the Emergency Room, and like Chelsey  Sullenberger,  the pilot who landed the plane in the Hudson, with  rarely used, but critical skills, doctors need to have history training for that, perhaps one time in their career, where it really matters.

Push. Pull. Evaluate. A Nod To A Great Colleague

Hope In Mental Illness

 

http://www.ush.utah.gov/dvd_philosophy_of_treatment.html

 

I love this video. I love how it ends with a person swinging on a rope, as a symbol of freedom from mental illness. I love how the narrator describes the understanding of the patient, from multiple points of view, critical to the therapeutic value that the hospital offers patients. I appreciate the philosophy as one which embraces complexity, as opposed to reducing mental illness into a cookbook of treatments. I stumbled upon it because I am reading another George Vaillant MD article to prepare for being a discussant this Friday. He mentioned that their philosophy was a model of treatment for sociopaths, as it contains them, while at the same time, allowing individuals to work together to change-up their aggression for productivity. I am not personally familiar with the care at Utah State Hospital, but if they do what they say they do, I am impressed.

 

 

Pill Mills

 

Most employed psychiatrists are hired to prescribe medication to the many folks who are thought to suffer from mental illness, while another practitioner provides psychotherapy and/or case management. At first glance, this seems appropriate. The psychiatrist is the only one in the mental health food chain who can prescribe, and hence, maximizing psychiatrist time, means having them do the most prescriptions possible. On the other hand, this narrows and denies the scope of psychiatric training, and in particular, it denies the value of the psychiatrist-patient relationship. For example, Sally, a fictional psychiatrist patient of mine, works for a social service agency, where she spends thirty minutes with each patient, ten hours per week, prescribing medication, but she feels, and I agree, that those thirty minutes are cherished moments in these severely ill patients’ lives. In this time, there is a frank discussion of their psychosis, their internal struggles, and their present worries, along with a prescription refill. This time is valued by both the psychiatrist and the patient as the healing relationship. The prescription is, in some secret way, almost an excuse for the psychiatrist and the patient to get together. In point of fact, the prescription could be written by a nurse practitioner, or more refills could be given, but the need for the prescriptions allows for quality time together. Sally reminds me that because our health care system is devaluing the doctor-patient relationship, the ‘work-around’ is to say the visit is for medication, but in fact, to use the time to build rapport. In my wishful life, I would like psychiatrists, like Sally, to come out of the closet and say that we need time with patients because our relationship with them matters, whether we prescribe medication or not. We represent a professional who can listen, understand and care about their internal and external struggles. We can also supplement our listening skills with psychopharmacology. Both are important. It is time to go public with our healing relationship with patients. We offer this to those who have hit tough times in their lives. We, as psychiatrists, should be proud, and not ashamed, of our bonds with those who seek us out. We are not, and should not be, pill-mills!

What Do Psychiatrists Do?

Private practice, county jobs, VA jobs, academic jobs, are all examples of how psychiatrists jump into a career. As I have ranted in this venue before, most psychiatrist jobs, these days, are what I call “psychopharm” jobs, meaning the institution hires the psychiatrist to be a “pill-mill”. “What’s wrong with this?” My imaginary readers ask, to help me launch into my current post. What’s wrong, is the psychiatrist should be the thought leader, the one who designs programs for the mentally ill or creates systems of care in which problems such as homelessness and substance abuse can be approached in a comprehensive, and compelling way. Checklists are not the answer, and yet, there is a large push, particularly in the public sector, for the practitioner to check off boxes, signaling that important issues are discussed. Yet, the issues of the mentally ill, be they anxiety or psychosis, is that the individual needs to feel deeply understood, and then there needs to be services which connect with their underlying pathology. Psychiatrists are in a unique position to both understand patients, as well as help other mental health professionals understand the deeply disturbing experience of mental illness. As such, psychiatrists understand the kind of social services that patients need. They also understand the kind of individual work a patient needs. Putting these two skill-sets together, creates a thought leader who should run agencies, direct programs, or design curriculum. Yet, in most institutions, those jobs are done by non-MDs. The psychiatrists fill the check-box of “psychopharmacology evaluation” and that is usually all they do. This is the big picture/small picture issue. We, as a field, have bought into the ‘small picture,’ without feeling the responsibility of the ‘big picture.’ For this, I think, my field needs to reflect and re-group.

Did Medicine Lose The Narrative?

Gene Beresin MD, Harvard Medical School faculty, wants to bring back the narrative to medical education. He made the point yesterday that coherent narratives help both patients understand themselves, and medical trainees understand their field. Narratives, he argued, creates attachment, and attachment creates security and comfort-crucial elements of a healing process. I am sorry, Dr. Beresin, as much as I fully support your mission, I am afraid that despite all of the advantages of electronic medical records, the major downside is the loss of the narrative. The stories are becoming much less important, replaced by symptom checklists and automated responses. I am not saying that medical care will get worse without the narrative, but I am saying that without the narrative, the practice of medicine changes its lure. Some folks,  like myself, are drawn to narratives. We love stories, be that in our patients, in books, in film or in theatre. The stories create a richness of life’s experiences which deepen one’s sense of oneself, as one begins to see a wider perspective of the world. So, maybe if I were coming of age today, I would be drawn to Eastern medicine, where the narrative still matters. Dr. Beresin, a man, I would guess, in his sixties, holds the old torch, making me nostalgic. He volunteered that he is also a musician, a man of the arts. That’s cool. Yet, despite his Ivy League credentials, I am afraid no mover or shaker in our health care system is going to listen. The value of the narrative is slipping away from the health sciences. It is too bad, but it is our future.

Autism Apps

http://www.latimes.com/business/la-fi-apple-autism-20130430,0,2782344.story

Can an ipad application help autistic kids communicate? The answer is nobody knows and everyone, especially those at Apple, those in the educational community, and families with autistic members, would like to think so. There is no evidence to suggest that any app can be useful, and yet there are “a search for “autism” in Apple’s App Store brings up 1,449 apps for the iPad, and 1,259 for the iPhone. And Apple has even created a “Special Education” section of the App Store.

The range of these apps has expanded well beyond the initial focus of helping people with autism communicate and improve social skills to learning about emotions and delivering basic educational lessons in a format that’s better suited to autistic learners, Shih said.

The creators appear to be drawn by a mix of instincts to help others and the sense that there is potentially a sizable market for these apps since, according to the Centers for Disease Control and Prevention, 1 in 50 school-age children in the U.S. have been diagnosed with some form of autism, an increase of 72% from five years ago.”

So, are we looking at a market which is highly suggestible, or is this the next great intervention? My intuition tells me that for children and adults with social/communication issues, the ipad or iphone is a tool, which although could be useful, for the most part, it cannot compensate for face to face time of social interactions. We learn to be social through experience, and yes, virtual experience can serve as a rehearsal, but the bulk of cooperation and reciprocity is learned on the playground. I am excited about the notion of health-care apps, where folks can carry around tools at their fingertips which can remind them to eat better, exercise and breathe deeply, but as with all interventions, there does need to be scientific studies to guide us how we can use these tools to most effectively shore up our deficits. Right now, we seem to be working with, and selling, hope.

Fungible

 

Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.

 

 

 

 

Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.

 

http://en.wikipedia.org/wiki/Fungibility

 

 

Automated Medicine Versus Personalized Medicine…Narcissism Versus Self-Care

 

Financing health care fascinates me. So many folks who have private physicians resist changing to a health maintenance organization because they will lose the “personal touch”. I, who have advocated for the value of the physician/patient relationship, am always shocked by this choice. Sally, fifty-one, for example, spends $1500.00/month for her and her husband to maintain their physicians. This number represents their premiums, not their co-pays, or deductibles. The could spend half if they switched to an HMO, and finances are really tight for them. Plus, she and her husband are healthy, and rely on their physicians only for yearly check-ups. Still, the notion that they can call Dr. Lee, and Dr. Lee knows them, means so much to Sally, that she steadfastly refuses to change carriers. “What if the quality of health care was the same at an HMO, perhaps even better, would you still consider switching?” I ask, Sally, curious by what might be a sense of narcissistic pleasing, which comes with more personalized medicine, as is the difference between levels of service at three star versus five star hotels. “I don’t know. It just feels bad for me to switch, so I cannot think of it.” Sally says in a dismissive way, although I am also aware that her initial reaction to my comment is one of negativity, she often gives it deep thought. We, as a society, get used to a certain level of service, making it very difficult, even in the face of financial hardship, to go down to a system which meets the goal of good health care, without the special treatment of someone knowing your name and your family circumstances.  Personalized care is often mistaken for better care. Automated care might not appeal to one’s narcissism, but it might get the job done. The rules of business prevail. Making people feel good sells. Outcome measures, or hard data, does not sell as well. Concierge medicine works on this principle. Business minded folks understand the rules. The public, unless mindful, are vulnerable to financial hardship as a result. The Affordable Care Act will bring these notions into the foreground. The change in level of service will be interesting to observe. The doctor/patient relationship will still be there, but it will be expensive. Service costs money.