Sunday, September 28, 2014

Utter Rubbish: A Call for a Moratorium on the 4 AM Blood Draw

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself.  Therefore all progress depends on the unreasonable man.  - George Bernard Shaw

Depending on the week and the driver, I am often awakened around 4 AM when one of several delivery trucks backs into the driveway of the restaurant beside my house, 15 feet from my bedroom.  Rankled, I have been known to open the window and have words with the driver, who, in my opinion, should park on the street, thus creating a distance between our house and his beeping, rattling, diesel-idling, polluting truck with its slamming ramps and gates and whatnot.  Because he mindlessly prioritizes a minute or so of his time over my and my wife's uninterrupted sleep.  Sometimes, we just get back to sleep before the next truck comes and awakens us again.

In relating this story to my father, he told me that the residents of a Northeast Ohio municipality recently passed a city ordinance banning the picking up of garbage before a certain hour, because of complaints of the noise and disturbance that the rubbish trucks cause at earlier hours.  Immediately drawing the analogy of the 4 AM phlebotomy visit in the hospital, my father wonders why, in the era of customer service, we subject the sick of society to this indignity and injustice while they're in the hospital.  And the answer is that I don't know.  A quick Google search is of little help.

There are two likely and possibly related reasons for the 4 AM blood draw.  First, in days of yore, physicians rounded very early in the hospital and then went to their office or to the operating room.  They wanted the lab results by the time they rounded so they could complete the rounding task and move on to others and not worry what Mrs. Jones' creatinine was all morning.  So, in essence, we have historically been awakening patients at 4 AM for physicians' convenience.

Wednesday, September 10, 2014

Helping Those Who Won't Help Themselves: The Role of Personal Responsibility in Medicine

Give a man a fish, or teach him to fish.
It is a well known secret in medicine:  many of those we care for are unconcerned with their own care, as evidenced by their revealed preferences.  "What medications are you on?" the physician asks.  "I don't know, doc," comes the reply.  "Why are you on carvedilol?"  "I don't know."  "What was your last HgbA1C?"  "What's that?"  We have encouraged physicians and other professionals in the healthcare system to take responsibility for every aspect of patient's care to the peril of patients' own interest and investment in their care.  How often do you enter a room and find a patient researching their illness and its treatment, rather than surfing the internet or watching TV?  Is your patient more concerned with the timing of the next dose of antibiotic or the next dose of dilaudid?  How often do your patients keep detailed records of their past medical history?  Why does the intern or resident or PA or NP schedule follow-up appointments for patients, rather than the patients do it themselves prior to discharge?  Why must so many patients be coaxed out of bed and working with physical therapy?  The actions of patients reveal their preferences.  Those who are invested in their own care take responsibility for it and are knowledgeable.  Those who would rather watch television than work with physical therapy reveal other priorities and preferences.

All the hubbub about healthcare and health disparities has entirely glossed over the role of personal responsibility and accountability in medicine.  Some may find it inexcusable that many patients have so little investment in their own health care, expecting instead that the government, their insurance company, and the healthcare system at large allows them to abdicate their own personal responsibility without consequences.
(I am not here referring to people who are unable to care for themselves, but rather those who are perfectly capable but who shirk the responsibilities.  If you cannot accept this and wish to accuse the author of "blaming the victim" read no further.  Yes, the victim of disease is being blamed for any lack of personal responsibility that is contributing to poor health.)

If there is a lack of personal responsibility in medicine, there are several important implications that we should be concerned about.

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.