Thursday, September 4, 2014

Mindless Medicine: The Importance of Minding Your P's and C's

I see far too much mental laziness in medical practice these days.  I will give some examples below.

To teach the residents mindfulness in diagnostics and therapeutics, I used to tell them to mind their P's and C's:

  • Problem:  What is the major malfunction that we are dealing with?
  • Proof:  Do we have proof of the problem or diagnosis?  Is there uncertainty, or are there other possibilities?
  • Cause:  How did this problem come to be?  Why is this happening?  Is there a deeper cause?  An even deeper one?
  • Cure:  What interventions should be employed to treat the problem(s) identified?
Sometimes I receive a call from the ER to admit a patient and the "presentation" if you would call it that amounts to rattling off a list of the laboratory abnormalities.  "What is the problem?" I ask.  "He's going to have to come in," is the reply.  No, my friend, moving the patient out of the ED is YOUR problem.  I'm asking what is the PATIENT'S problem.  You are here, after all, to serve the patient, right?  Some ERs appear to be evolving into glorified triage centers, with a primary focus on differentiating those who can be sent home, flown out, or admitted, rather than centers focused on making expedient and prompt provisional diagnoses so that time sensitive therapies can be administered post haste.

Other times I get a call that a patient has DKA.  "Why do you think that?" I ask.  "Because his sugar is 600 and his bicarbonate is 14 and his anion gap is 24," comes the reply.  "Are there ketones?"  Lo and behold, there are not.  But there is lactate and sepsis, and in one case there was ethylene glycol poisoning.  The proof of DKA requires demonstrating diabetes, ketones, and acidosis - hence the acronym DKA.

Or, I'm called by the internist about a "pneumonia" that is not resolving.  "How do you know the patient has pneumonia?" I ask.  (It's notoriously difficult to "prove" there is pneumonia, unless there is antigenic evidence of Streptococcus pneumomiae or Legionella pneumophila.)  I'm told there are infiltrates on the chest x-ray.  Ultimately, a trial of diuresis clears the infiltrates within 24 hours.  The failure to recognize that proof of pneumonia did not exist led to closure of the mind to other possibilities when the patient did not improve along the expected time course.

"I got one for you," proclaims the freshly minted ER doc who is mindlessly ignorant of how grating and abhorrent that phrase is.  (I got something for you too, Buddy.)  "What's the problem?" I ask.  "She's septic," comes the reply.  But there is no source, no cause identified.  The chest x-ray is said to be clear, the urine is not back yet, and the patient is obtunded.  "It's probably the urine," says the mindless neophyte, bent on clearing out the ER before shift change.  Or it's a perforated bowel.  Or meningitis.  Or Fourier's gangrene.  "Back to work, Buster!"

Similarly, it is inadequate to diagnose heart failure without searching for the cause.  Ischemic?  Viral?  Alcoholic?  Likewise, pneumonia.  Is it sporadic, like community acquired?  Or is the patient aspirating?  Why are they aspirating?  Bulemia?  Booze?  Narcotics?  Advanced age and poor functional status?  An incipient neurological disease?  Does the patient have HIV or other immunocompromise?

Finally, the cure.  This is included because even when the diagnosis is correct, proof exists, and the cause has been identified, a search for all the necessary interventions may be incomplete.  That patient with spontaneous bacterial peritonitis to whom you are giving cefotaxime - don't forget the albumin, and don't forget prophylaxis once treatment is "completed".  Oftentimes a visit to www.uptodate.com will jar the memory of the subtle nuances of the holistic treatment that are otherwise forgotten - like pulmonary rehabilitation in COPD patients, meningococcal vaccination in splenectomy and sickle cell patients, correction of iron deficiency in heart failure, etc.

This is all just another way of saying that an intellectually challenging endeavor like diagnosing and treating medical diseases requires mindfulness and effortful, deliberative thought.  And remembering that is perhaps the most important thing for practitioners - you are engaged in a professional endeavor that requires mindful, deliberative, effortful thought for optimal results.

If you are a patient, I encourage you to ask your doctor about the PPCC of your particular medical complaint - to make sure s/he is being mindful.  Let's call that involuntary or forced mindfulness.

8 comments:

  1. I think my blood pressure shot up while I was reading this. As someone who also takes a lot of ED call, I have the same thoughts a dozen times a month. Can I add to your list: 'bowel obstruction'? This is a condition, not a diagnosis. And with the sensitivity of CT scans these days over half of these kinds of calls are actually ileus or enteritis. The next question I have will likely be, "What surgeries have they had before?" or "Do they have any hernias?", and about 75% of the time the answer is some version of: "Oh...I don't know, I didn't check". It's can be so frustrating. You have to constantly balance a) not trusting anyone over the phone, and b) triaging the best you can in these conditions because taking so much ED call would not be tolerable if you snapped to every patient's bedside like an in-house resident (nor do many patients really require that level of response).

    I was in the doctor's lounge a few weeks ago and had an ED doc complaining to me about the pressures other doctors put on him and his colleagues to have a diagnosis when calling practitioners, implying that it was beyond what should be expected from them. In my head I'm thinking: why do you get to be paid so much if you don't want to put any thought into what you're doing?, because you are a MD/DO so that is absolutely your job. Like you say, I'm not expecting a precise diagnosis, just a thoughtful description of what's going on, a ballpark idea or two, or some evidence of doing what I would expect a MS3 to do.... And, not to beat up on ED docs too much, the hospitalists can be just as bad.

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  2. Wow, no ego or intellectual laziness in this article.

    Here's how it reads to someone not as in awe of your brain as you obviously are:

    Intro: Everyone other than me is lazy and stupid, here's some examples:

    I: I need a mnemonic to make sure I use my brain, its called P's and C's, I used to teach it to residents.

    II: Sometimes the ER calls and doesn't give me a coherent presentation. Maybe that's because they see me as obstructive or difficult, or maybe its just because they're stupid and I'm smart. Certainly its not because they have a similar understanding of disease as I do and are simply trying to not waste your time holding your hand through connecting the dots. I'll just assume its because I'm smarter than them.

    III. Sometimes they call with DKA. They're so stupid they don't know what DKA stands for. Of course, its not that they are aware of the poor sensitivity of most hospital ketone and ACE tests for ketosis and certainly they can't rattle off the most common ketones in DKA compared to the tested ones. Oh, and here's one example of where somebody made a big miss and I'll go ahead and characterize all of the calls as identical (sepsis, which by the way can and does co-exist with dka - ie the presense of one does not exclude the other).

    IV: "I got one for you" - I think there's pretty valid points in that paragraph although called someone "freshly minted" and "mindless neophyte" don't really make you stand out as an intellectual honest person. More like academically elitist, judgmental, and mean.

    Remaining paragraphs: I wish they'd just do my whole job. I mean, why can't they wait until the HIV test, echo, psychiatric assemesment all come back before they call me.

    In short, I think your article as just a rant of someone who is unstisfied and feels a little to good about their abilities. This sounds like something an intern would write before they spend a decade or so learning that all of their colleagues work pretty hard and are pretty smart and talking bad about other specialties (or good about yourself) is an obvious and pathetic attempt at self esteem. They go on to realize that any specialty can write a nearly identical piece about another specialty.

    I'm not trying to be harsh. Medicine is tough for everybody, but I don't think lashing out in this way is healthy or wise.

    Lastly, I'll say that if you're having problems with your interactions with the EM docs or consultants it may be because they perceive the feelings that you espouse here. How well would your presentations go if they wrote a similar article?

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  3. Sometimes reality is harsh and painful. Defensiveness can be evidence of the effects of reality on people's feelings.

    Were the commenter above to care more about reality and quality of patient care and patient outcomes than s/he does about the feelings of his poor beat up on colleagues, he would have said:

    "Jesus Christ, did an ER doctor REALLY call and report that an ethylene glycol poisioning was DKA? REALLY? If he did, he ought to be fired. He's making us all look bad. And, somebody could have been maimed or killed by his negligence."

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  4. Okay, I'm not going to get in some type of internet argument with you.

    I will say that if someone called you with ethylene glycol poisoning as dka and you caught it, thank you for helping the patient - good catch. Shame on you, for needing to trumpet your success on the internet and lumping a whole group together from one (exceptionally rare) case. Shame on you for thinking that no one has ever saved your patients tail by catching a mistake you made. They probably just didn't need to brag about it on the internet. Shame on you for lacking the critical thinking skills to see that the second person to see the patient has to be smarter - they've seen more information, time has evolved and heard another persons opinion about the case. If you don't have a good catch one out of every 50 patients then you're doing it wrong.

    Good catches are great, but don't require bragging. True malpractice or negligence requires formal processes that don't involve pumping ones ego up on the internet.

    This article reads like someone who never talks to anyone outside of their specialty. Why don't you show it to one of your Emergency Medicine colleagues and ask for a thoughtful critique of how they read it. I imagine you'll trust their opinion more than some random guy on the internet. I just hope you get a chance to learn from it. Our patients are not served by specialty bashing or academic elitism.

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    Replies
    1. If the commenter is right, she has identified a pompous arrogant egomaniac tooting his horn on the internet.

      If the commenter is wrong, she has failed to recognize serious safety and quality issues in the delivery of medical care in the ED elsewhere, and potential means of minimizing them through mindfulness.

      Clearly, the biggest risk is if the commenter is wrong.

      If the commenter wishes to be mindful, she may wish to explore the literature on mindfulness (e.g., Ellen Langer), Judgment and Decision Making (e.g., Daniel Kahneman, Thinking Fast and Slow) and Decision Biases and Cognitive Forcing Strategies in Medical Decision Making by, ironically, P Croskerry, an emergency medicine physician.

      Should the commenter not be interested in investigating these themes further, she has, in her mindlessness, provided a note of entertaining irony for this blog post. For this post is not about egos, and one upmanship, it is about serious medical decision making errors, and only a mindless person would gloss over the seriousness of that charge.

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    2. "If the commenter is right, she has identified a pompous arrogant egomaniac tooting his horn on the internet.

      If the commenter is wrong, she has failed to recognize serious safety and quality issues in the delivery of medical care in the ED elsewhere, and potential means of minimizing them through mindfulness."

      What if both of these statements are true?

      It may be so that your colleague is less than competent and should be more conscientious. Heck, if I were you I would raise this issue with the offender, and if it continued, higher ups. That said, a 5 year old should be able to tell that you are, indeed, arrogant and unnecessarily derisive.

      It really doesn't take much to tell you're not exactly high on agreeableness.

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    3. The derisive are derided by 5-year-olds, said CJW sardonically.

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  5. When admitting a patient in the evening... its both the patients ass and yours that are on the line... relying on the ED handoff as the basis for hours, to over a half day of interim care. Of course we should demand that thought be placed into the admit disease/ condition/ treatment.

    The art and science of the field has deteriorated under the shift towards profit, protocols, and medico-legal implications. Medicine as a whole is in a sad state.

    Harry

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