Monday, March 18, 2013

Worshiping Relics of the Past: The Physical Examination

It seems like every year or so, an article such as this one is published in just about every medical journal either lamenting the withering importance of the physical examination (PE), bemoaning contemporary physicians' indifference to it, inventing creative perspectives to enshrine and hallow it, or just harkening back to the "good 'ol days" when that was "all we had."

The whole state of affairs is ironic and silly, for several reasons.  I would be shocked if the same doctors who hanker after the good 'ol days of Valsalva and Mueller maneuvers, Austin-Flint murmurs and Cannon A-waves don't carry around iPhones, iPads, Up-to-Date Apps, and every other manner of advanced electronic device, aid, and tool.  (They are probably also vocal proponents of EMRs.)  They don't dust off an old EKG machine from the 1960s once a week and teach medical students how to use it just in case they find themselves on a medical mission in Cuba one day.   They use computers and statistical programs to perform calculations for their epidemiological studies, not slide rules and Z-score tables.  If they have a mortar and pestle, or an old microscope, it is on a shelf under various diplomas, testaments to the past and nothing more.  So why all the fuss over the slow but inexorable obsolescence of the PE?

Monday, March 4, 2013

Ventilating Corpses and Resurrecting the Dead: The State of Modern Critical Care Medicine

I vividly remember being chided by the ICU Director in my residency during ICU rounds one morning, circa 2000:
Director:  "Scott, why did you intubate this man?"
Me: "Well, Dr......he couldn't breathe and the family...."
Director:  "Scott.  This man has metastatic anaplastic thyroid carcinoma.  He's dying.  We're not in the business of ventilating corpses."
But ventilating corpses is indeed the business of modern critical care medicine.  I'll leave it to you to decide whether that's a good or a bad thing.  But in so doing, you should grapple with the data and the larger issues.
An article the February 20, 2013 JAMA describes ventilation weaning practices in an LTACH (Long Term Acute Care Hospital).  It is a very well done study that confirms what I already thought I knew:  that tracheostomy mask weaning is superior to playing around with pressure support levels.  Well and good.  But there's an elephant sitting on the article:  two thirds of the randomized patients were dead by 12 months, regardless of whether they were weaned or not.  Two of three patients were dead.  Despite undergoing prolonged intensive care, receiving a tracheostomy, being sent to a veritable nursing home, and probably being artificially fed, and despite all the suffering, physical and mental, emotional and spiritual that this entails, two of three of them were dead at one year.  And this is not a new finding:  the data on 1-year mortality for tracheostomy patients in an LTAC in this article comport with those of other studies such as this one by Kahn in JAMA in 2010.
We need to begin, as a society, to seriously question if this is a good thing to be doing to/with the dying, which will one day include us.  Namely, should we PEG, Trach (verbs), and send the dying to a nursing home for a prolonged trial of weaning from which only one of three of them will survive?
The authors introduce the subject by describing the expansion of LTACHs in the US over the last decade (from 192 in 1997 to 408 in 2006), and their associated costs ($1.3 Billion in 2006).  They also note that because of the aging population, there is an anticipated 38% increase in demand for intensive care physicians in the next decade.  But they make no mention as to whether these increases are desirable and appropriate.  One possibility is that these increases reflect a misguided way of dealing with death and the dying.
But being alive at 12 months does not mean being well and it most certainly does not mean back at home as though the index illness never happened.  The probability of being alive and breathing without assistance after one year for a patient who goes to an LTACH with a tracheostomy is on the order of 25%.  The probability of being alive, breathing on your own, walking and eating and urinating normally?  I don't know, but it's less than 25%, I suspect a good deal less.  The probability of living independently?  Less than 10%.
And I can tell you from vast experience that the majority of patients and their families, when in possession of these statistics, do not want a tracheostomy and an LTACH and all the associated encumbrances and miseries.  Then why are so many patients receiving tracheostomies and going to LTACHs?  Because their physicians are not arming them with these statistics - or they think they are, but they are victims of wishful thinking and patients and their families are not receiving the message that physicians think they are delivering.  And why is THAT happening?  Probably a lot of reasons, but I think the general notion can be summed up by an analogy I introduced at a Division of Pulmonary and Critical Care Medicine conference about 6 years ago at Les Wexner's Ohio State University Medical Center.  I was dumbfounded by how little critical thought was given to the accepted wisdom that a PEG and a tracheostomy and a discharge to an LTACH was considered a success by those practicing critical care medicine.  Here's the analogy I challenged them with:
Suppose I give you a superpower.  With this superpower, you can resurrect the already dead, and restore them to life, but it is a life dependent on a PEG and a Trach and an eternal existence in an LTACH.  How many deceased (and in peace) people would you resurrect with this superpower?  A hundred?  A million?  A billion?
(Obvious corollary questions are:  how many people, as a society, can we afford to support in LTACHs?  How many people would want to be thusly resurrected?  A philosophical discussion about status quo bias could also ensue.)
Silence filled the room.  Nobody responded.  I think they assumed I was being absurd, and this absolved them of responsibility for giving serious consideration to the issue I was raising.  And this failed responsibility is how we got here in the first place.  Because nobody is questioning the current status quo.  Rather we congratulate ourselves for "saving lives" and celebrate the anticipated rising demand for our kind.  Hooray, our disservice is in demand!