CYA and Healthcare Reform

September 27, 2009

Ok, so I know that I haven’t written a post for some time now and you are about to understand why. About one month ago, my dad called me to tell me that his primary care doctor had instructed him to go to the ER immediately because his routine EKG showed a change from last year. She had in fact stressed him out to the point of probably giving him a heart attack with her behavior which included wanting to call 911 to take him directly to the ER from the clinic.

Was he having symptoms (chest pain, shortness of breath, diaphoresis, decreased exercise tolerance)? No. In fact, he felt totally normal. Was he having ST elevation or depression on his EKG (findings typical of heart attack or diminished blood flow to the heart respectively)? No. He had “nonspecific t-wave changes”. Were his vital signs concerning? No. His blood pressure was 128/72, heart rate was 88. So why call 911? Because the primary care physician wanted to practice CYA (cover your arse) medicine.

For some reading this post, the term CYA medicine might be something of a novelty. Certainly one never sees Dr. House, MD or Dr. Cox from “Scrubs”, or even Dr. Green and Carter from “ER” practicing this type of medicine. What exactly is this type of medical practice?

It basically involves the most limited degree of mental commitment possible in a medical encounter, where you are asking yourself only one question, “How can this patient hurt me later?”.  Based on the medical provider’s answer to that question, they then proceed accordingly. It doesn’t matter how much this will cost the patient – insured or not. It doesn’t matter how many needless tests you have to order at the patients physical, financial and emotional expense. It also doesn’t really matter if the patient agrees with you or not, especially if they are insured – because you can always threaten them with an AMA (against medical advice) discharge where their visit will not be covered by their insurance. They are your prisoner so you can strategize your defense from a medical malpractice lawsuit.

As an ER physician myself, I cannot always blame providers who practice medicine this way. I don’t believe that anyone graduates residency intending to practice medicine this way. Its after someone comes after you for something only God could have forseen that you get gun-shy. At the end, it becomes a vicious cycle of abuse from both ends.

This is the biggest problem with Healthcare reform – the hidden nooks that politicians can’t see the way we, as healthcare providers, see them from within. There are too many groups mining in the medical gold mine – malpractice lawyers, insurance companies, drug companies, etc. – and they each have powerful lobbies to back their interests. The purity and simplicity of the doctor-patient relationship with all that it used to contain of trust, friendship, understanding and forgiveness has been plundered and I personally am not sure we can return to that after having let in the greedy pirates mentioned above.

So, back to my dad. He asked me to come with him to the ER – in my car and not the ambulance – to make sure they didn’t rape him there with unnecessary tests and procedures. He had me stand behind the ER provider who was practicing CYA and give him thumbs up or down depending on whether I agreed with the management or not. They of course told him that he could die if he wasn’t admitted for “further testing”, but he did just fine at home until his next follow-up appointment.

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Creepy Love and Other Relationship Oddities of the Week: I

July 18, 2009

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From time to time in the ER, we have the unfortunate experience of seeing relationships so foul that they can only be called “creepy love” as a nurse so aptly put it one night. It is just the sheer volume of people that we interact with that necessitates, to some degree, that we see all sorts of oddities. To narrow it down to just a few is so hard that I decided this would only be one part in a mini-series. Prepare to be horrified.

Creepy Love #1  goes hands down to a mother and son team that came in last night. The son, a young man of 19 years, presents with mom because his testicles hurt. Ok, nothing weird so far. Before I go in the room, I see mom step out as he gets gowned, something totally expected. I figured she would stay in the waiting room till he got discharged. Wrong.
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As I start the exam, Mom returns. I tell her from behind the curtain that we are about to examine the private area and if she would be comfortable returning later. To my surprise, they both – almost simultaneously – say no. So, she comes back to watch me examine her boy’s family jewels.  Afterwards, we come to the a set of questions of what he was doing when his balls started to hurt.  I am totally amazed as he goes into a detailed description – again in front of Mom – of how he was making out with a girl for “a really long time” without hitting the pay-off at the end. So, I told him that most likely he was suffering from a case of  “blue balls” – or testicular vasocongestion in medical speak. 
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Mom very creepily laughed at this point and told me that this is what she had suspected as well. I thought to myself, “If she starts talking about how this kid’s Dad used to get blue balls when they were still a fledgling couple – I am outta here!”  Usually young men cross the – Mom, “this is kinda private” – line around 15 years old. 16 wouldn’t be weird. 17 is pushing it. College age is already weird. But 19 going on 20 is just creepy (this guy is about to start junior year in college).
 
Creepy Love #2: Young woman – 25 years old – presents to the ER after having a fall the night before when she was plastered. There is a gentleman (used very loosely) in the room with her who appears to be in his 50’s. I’m thinking Dad, but I learned a long time ago to not assume anything in this area (We’ve all been there before – “So, this must be your Mother right?” Patient’s wife replies in a very insulted tone, “Mother? I’m his wife“. Ohhh – can the Earth please open up and swallow me now please).
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So, I casually wait for a moment to ask the man, “And you are?”. He replies that he is a “good friend“. Another lesson that I have learned is that “good friend” can also mean any one of many things. Apparently, Mr. Good Friend was with this young lady at the bar last night and drove her home. So, I’m thinking maybe he lives on the same street – saw his neighbor trading sober for hammered and kindly offered to take her home. No, that would be too normal. This was all about the creepy.
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So, since she had fallen in her less-than-sober state, I needed to check certain areas of her that were still clothed. I told her to get gowned and that’s when the creepy-meter hit red. I walked out of the room to let her get undressed – and he didn’t.  Now I know you’re thinking, it isn’t necessarily weird for an older man to date a younger woman less than half his age, and that in some ways it can be totally socially acceptable. Believe me, this wasn’t one of those cases.  
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The last couple for this post wasn’t a creepy one at all, just a sad one. 55 year old man comes in with chest pain. There is a woman with him who looks like she fell from the ugly tree and hit every branch on the way down as well as ate bark. But I really do believe that beauty is partly from within and not only skin deep – so I really didn’t think much of it. Until I started the interview.
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Everytime this guy would try to answer a question, this woman would literally scream at him and say he was lying. Then she would tell me something else. He didn’t seem to fight it, so I could only assume she was right. It was more typical of the way an angry mother would correct her delinquint son, but this was husband-wife dynamics.
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When we got down to the social history, the guy turned out to be a regular drinker. Imagine that. I mean, who wouldn’t want to be sober to deal with a delightful woman like her everyday? To understand this dynamic better, I researched the net and found this interesting article: Top 10 Signs She’s a Bitch. Oddly enough, the first comment to that article was written by a man who called himself F@&k Me who wrote: “what happens when you’ve been married to one for 17 years, and just can’t take it anymore?”. I guess my patient was asking himself the same question everyday as he cried into his drink.

Coping Skills Don’t Come in Pill Form

July 9, 2009
Just swallow

Just swallow

OK, I promise to write more often (thank you all for the kick). June and July are always mega-busy as everyone tries to go on vacation, and then you get a Dumass doctor fired and it just makes things that much harder on everyone.

One of the saddest commentaries on the modern world that I see on an all too regular basis is the absolute lack of coping skills in the growing generation. We had generation X and then Y, and I guess they’ll need to call this generation W for whiners. Too pampered while growing up that they have no idea how to manage their own problems after they very effectively create them.

Case in point. This past weekend, I had the unfortunate experience of seeing LT on three separate occasions for what he described as “anxiety or a panic attack”. LT was a promising college football recruit out of his competitive high school district. I have no doubt that he was getting his bum kissed all the way through high school and well into college until he blew out his knee.

He went to surgery for his ACL, but being that LT had always had others to take care of him, he ended up with an infected knee and a PIC line. The nurses in the ED came to know him well as he would often roll into the ER for his scheduled IV antibiotics after midnight while drunk and with a different girl on his arm. And things would only get worse …

Soon after, one of his girlfriends got pregnant and decided she didn’t want him in her, or the newborn boy’s, life. On one of his drunk escapades, he got into a fight with some guys on a street corner. For some reason though, he was the one arrested (they were all the same ethnicity by the way). Since his knee was no good now, he also lost his scholarship and with it, the stream of girls who had followed him around.

So now he had only one girl left and a growing list of problems. So poor LT thought he was going crazy and came to the ER. There he received an rx for Paxil and some Ativan to help him calm down. Little did I know that he would be back a short 10 hours later. He told the nurse that the doc he had seen earlier “hadn’t taken the time to talk to him”. He was surprised to see that it was still me though and quickly backtracked by saying that what he meant was that he hadn’t had enough time to fully explain his problems.

So, I listened patiently to him as he told his sob story. Afterward, I explained to him once again that he was not crazy but that he had several issues that he would need to address one at a time (just like the rest of us mere mortals). He didn’t seem to like my suggestion as that entailed actual effort on his part. I resisted the urge to ask him if his girlfriend wipes his butt for him as well.

The next day he showed up yet again, this time saying that he felt chest pain. I was obligated to do more of a work-up this time – which was completely negative 80 minutes and $5000 later. I had no desire to see him again in what remained of my ridiculously long shift and hit him with the B-52. When his mother, I mean girlfriend, came to pick him up he was already half-way to his “happy place”.

Thinking I was done, I actually rested. But less than 2 hours later the police showed up with an inmate who had swallowed shampoo and some toothpaste in a suicide attempt. I asked him why he had done that, and he said that he couldn’t handle being in jail anymore. He was put in jail 3 days earlier for DUI. I thought to myself, “you really don’t know what being uncomfortable is all about – yet.” Then I got out the gastric lavage.

I don’t think he had bargained on getting a garden hose put into his stomach without sedation. But he just couldn’t get it through his mind that he needed to find a way, other than medicine to “knock him out”, to cope with prison life. The whole “do the crime, do the time” thing just didn’t compute in his mind.

The future scares me.

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A Review of Showtime’s Nurse Jackie

June 15, 2009
She Does What we Only Wish We Could Do to Some of our Patients

She Does What we Only Wish We Could Do to Some Patients

I recently watched the pilot episode of Showtime’s new show, “Nurse Jackie”, with the night crew. Jackie, played by Edie Falco, snorts crushed vicodin, steals money to give to the poor, forges an organ donor’s card, has sex on the job with the pharmacist who supplies her with the vicodin and flushes an arrogant jerk’s ear down the toilet after some choice words – and that’s just in the first episode.

In many ways – sex and drama aside – Nurse Jackie is the quintessential “take-no-crap” ER nurse that has served as an experienced den mother of sorts to so many young doctors and nurses still finding their way in the medical field. I still work with , and learn from, nurses like that, who continue to enlighten me with their experience, wisdom and knowledge. And no, I didn’t grab their boob or have sex with them in the supply room.   

On one hand, I fear that people will actually believe that nurses behave this way and treat them with even less respect.  I guess we will just have to leave it to shows like ER and Hawthorne to teach people to respect and admire the amazing efforts that nurses make to brighten, save and enrich so many lives on a daily basis in hospitals and clinics throughout the world. It is a noble profession that is too often the unsung hero. But back to the show …

Although it does present a flawed character portrayal of nurses, it is kinda fun to see someone act out what we all sometimes wish we could do with at least some of our patients. She has a distorted sense of ethics that leads her to do what will in the end be the most benefit to society in her opinion, and other times just gives people what we all know they really deserve. Except maybe her poor husband, but maybe the reasons for that will play out later.

From a doc’s perspective, I thought the whole Heimlich scene was coldly amusing. I get a similar feeling when responding to “Is there a doctor on the plane?”, because you really are never on vacation as a medical professional. It is a blessing, and sometimes it can be a drag, but no doubt it is wonderful to always be able to impact people’s lives – although not always in such dramatic fashion.

The nurses who watched it with me – male and female – enjoyed the show and were looking forward to future episodes. It presents an entertaining contrast to shows like ER and Grey’s where political correctness sets a border around the characters. So many of us in medicine hold back what we really think of some of the pathetic excuses for humanity that we see on such a regular basis from the the drug seekers, the self-righteous and those who feel they have the “right” to put us down, the domestic abusers who beat on their spouses, all the way down to child abusers and those who have children when they have no intention of doing anything remotely resembling parenting or loving, etc. It might just provide an outlet for those of us who bite our tongue and “do the right thing” even when it would feel so good to tell these people what we really think.

What I really want to know though is why the pharmacist has a bedroom in the hospital?

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The Radiologist Examined a Patient!

May 30, 2009

Those of us in the medical field know the radiologists – the doctors who read xrays, CT’s, etc. – usually sit in their dark room all day and read films, often times with CYA statements at the end of their official report that say something like, “_____ cannot be excluded, and so a [another imaging study inserted here] would be recommended …”.  The type of person who typically goes into radiology is a person who doesn’t much like dealing with other people, and so they only “see” patients when, and if, they have to do a procedure, or if they pass them in the hall. It is rare that I even have the chance to discuss my clinical exam with a radiologist since they don’t usually seem to care about our seemingly worthless thoughts.

But in my hospital, I have the great honor (doesn’t always feel that way) of working with some of the smartest doctors in the world when they moonlight here away from their Ivory Tower. Their hospital is internationally recognized as one of the best medical centers in the world. Among this distinguished group are the radiologists that will moonlight here on weekends. I have to say that some of them have their nose so stuck up in the sky that we only look like ants to them, and that is how they speak to us. But something cool about medicine is that experience almost always trumps medical training. There are many nurses I would rather have treat me that some of doctors I have had the horror to meet.

So, last week I came into work and my first patient was a poor old woman who was run over accidentally by her husband with a farm tractor. I called to request a CT of the chest, concerned about flail chest and significant thoracic injury. The Ivory Tower radiologist balked at my request and stated with great annoyance (how dare I interrupt his computer game) that he would read it, but that he thought it was totally unnecessary. He felt a simple x-ray should provide adequate information. I responded by saying innocently that I was unaware that x-rays would show vessel damage since after all there are some big pipes running through the chest (aorta, IVC, subclavians and oh, that darned thing that keeps beating).

He made getting the CT a chore as well (some sort of punishment I suppose) by having the techs refuse to do it until I checked her kidney function. It was a trauma! Why should I wait for kidney function? But they insisted.

He humbly called me back an hour into this poor woman’s ER course to tell me, “Man, this lady’s really messed up!” I asked if that was his medical diagnosis.  The “official” report was that she had broken 10 ribs on one side, had a collapsed right lung, and bilateral lung bruising. Nah, we didn’t need that CT now did we? I resisted the urge to rub it in and focused on taking care of the patient instead.

But every now and again, we do get an exceptional resident from the Ivory Tower. This weekend, I have the true honor to work with one such radiologist. Professional and personable, so much so that I am almost convinced that he is not a radiologist by training. Maybe he’s like that guy from Catch Me If You Can? He doesn’t call us to give us reports, but comes in to see us in person on almost every case in order to discuss the case and provide his report. This not only makes him courteous, but way smarter than the other radiologists because getting the clinical backdrop is a very good way to not miss something important. When you understand in detail why the test was ordered , it helps you zoom in on the area of concern with a different perspective.

But then he did the unthinkable. Our stellar resident actually went and examined the patient! I don’t think that in all my years of medicine I have ever witnessed such an event. I thought radiologists had lost the art of examining patients by the time they finished their internship, but this guy proved us wrong. Kudos to you my friend and maybe you will be an inspiration for the others in your field to come back down to earth.


When Funerals Go Bad

May 26, 2009

While at work yesterday, I overheard the ambulance going out to a call at a graveyard. Now, I personally like to give everyone at least one round of ACLS no matter how long they were down prior to arrival, but I think you have to draw the line somewhere right? In the end though, it turned out to be nothing. It did remind me though of one bizarre funeral that I received some clients from once while working in the South.

Family members had gathered for the funeral of someone who had died young. While the eulogy was being given, one of the deceased man’s brothers couldn’t contain his grief any longer and tore open the casket, dragging his dead brother out in front of the whole family so he could hold him. Needless to say, people started fainting, screaming, crying and the rest were just frozen in horror at the macabre proceedings.

I received two people via ambulance from this funeral with complaints of anxiety and fainting. Nothing a little bit of Ativan and a lot of counseling couldn’t handle though. I never did get to meet the hulk who ripped open the casket though. And that is a very good thing.

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Contributing Factors to the Current Physician Shortage

May 16, 2009

As early as 2005, predictions were being made of a coming shortage of medical providers for the United States. The reason that was primarily referenced for this coming shortage was a lack of adequate forecasting for an aging baby boomer population as stated here in a 2005 USA Today article:

The country needs to train 3,000 to 10,000 more physicians a year — up from the current 25,000 — to meet the growing medical needs of an aging, wealthy nation, the studies say. Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon.

Certainly, there is truth to this idea. I personally get numerous job offers on a weekly, and sometimes daily, basis. But there is something that these studies and articles are missing. A number of doctors are also getting so fed up with medicine that they are choosing non-clinical careers; careers where they don’t do patient care.  This includes working for drug research companies, writing/editing, educating and even leavingmedicine altogether. I read an interesting article on-line by Dr. Kent Bottles in a Physician’s News Digest from 1999 that discussed some of the discontent doctors are feeling these days:

There’s a 1998 survey by Levin of 6000 physicians in 22 different cities that revealed that 46% of all American clinicians often think about leaving clinical practice. That’s over 300,000 physicians in the United States that seem to be unhappy with the state of affairs. There are other indications about physician discontent that you might not think of readily. The number of disability claims by physicians has increased so much that some insurance companies no longer are writing disability insurance for physicians. Recently the AMA, one of the more conservative organizations of physicians, has voted to form a union. And another example I saw was an article that said that physicians are actually moonlighting by selling cleaning products and herbs out of their homes. So, for a lot of statistical reasons and for a lot of those more soft reasons, it looks like physician discontent is widespread and happens throughout the whole country.

I am also personally one of the aforementioned doctors who has thought of doing something else with my life. Medicine has changed so much that it has become unrecognizable to some of the older docs, and it can sometimes be down-right depressing for younger ones like me. Sure, all jobs have the good and the bad right? But to me it seems somewhat different when you dedicate 10 years of your life to learn a skill and then have someone accuse you of intentionally and knowingly trying to harm them.

I posted an article yesterday about how we, as medical practitioners, had misled people regarding the “threat” of Strep throat. I stated that, statistically speaking, the risk of serious side effects from antibiotic use for this condition outweighed the benefit. And in turn, I received comments that reflect what we all unfortunately hear in medicine from time to time. That we “don’t care”, or that we diabolically “want people to suffer”.

To me, this arrow stings the most. That someone would really think that because I make a certain medical decision, that this means that I intentionally wish to harm them or cause them to suffer needlessly. Maybe I’m too young and haven’t yet developed skin thick enough to deflect these barbs. And then again, maybe I never want to develop such thick skin. If I did, then I wouldn’t be able to muster the compassion for other people who do trust us and don’t want to just give us orders.

Overall, I think it is a global phenomenon of lack of manners that has developed. As a doctor, I am humble enough to say that I will not be right all the time, and I don’t have to be. What I am charged with doing though, is not harming my patient. If you are a patient and reading this, please remember one thing. You can always get a second opinion. You don’t have trash someone just because the one snippet you heard on Oprah or read in Time magazine seems to contradict your doctor’s decision or advice.

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