Flawed and unethical, but I bet it would work:

1. Alert the media that for the coming week, everyone will be DNR/DNI until proven otherwise, instead of full code.
2. Miraculously watch as everyone rapidly develops a living will, durable power of attorney, and talks about their wishes with their loved ones.

You would’ve thought the Terry Schaivo thing would’ve done this already, but I seem to get all the patients who have no idea what they want. Just last night, an elderly Hispanic man was admitted for possible heart failure and possible heart attack, and after a lengthy discussion about code status, he tried to give me this innocent little indecisive giggle-shrug-smirk, as if I asked him what type of food he wanted to eat for dinner and just wanted to be agreeable. This ain’t one of those types of questions. You need an answer.

On a more ethical but medically ethical topic, some people propose making the organ donor system an opt-out system, where one would automatically be consenting to donate their organs unless they specifically said they didn’t want to.

*A person’s code status tells the health care system what he or she would like done if their heart stops or lungs stop working–would they like everything done (full code) at one extreme, or would they like no measures taken (DNR, DNI – do not resuscitate, do not intubate). You can pick any level of code status, and have specific parameters as well.

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Call me crazy (“Hi, Crazy!”), but I think we need to start changing the medical school curriculum a bit.

One of the main focuses of the pre-clinical and clinical curricula is teaching the medical student the art of the differential diagnosis. You basically take someone’s symptoms, and try to figure out what’s causing their disease–any number of body systems can cause similar systems. And as the saying goes, “You can’t treat what’s not on your differential.” That is, you’ve got to consider everything, so if it’s not what you think it is, you’ve got a fallback 2nd or 3rd idea for what the problem could be. Obviously important to reinforce this concept into our heads. Over, and over, and over again. And then over some more.

But one area where I think we’re lacking–because medicine has changed so much–is the treatment of the chronic disease. We focus so much on the acute still in medicine, when our patients have primarily shifted to the chronic. Sure, as residents we have clinic time where we see patients as outpatients in a chronic disease setting–but most of our residency (and much of our medical school) training is still focused on the acutely ill patient. While this definitely hammers home important concepts in many diseases, which can then be translated to the outpatient basis, I wonder if there’s more we should be learning. If you look at physicians as a whole, they’re not working in hospitals, taking care of acute patients. They’re working in private practices, seeing outpatients.

What should change? A couple ideas:

1. Focusing on trends, not on specifics
2. Focusing more on prevention if the disease will be life-long
3. Time management with patients
4. Changing the culture so that patients expect to come in when they’re well and when they’re sick
5. How to stay energized and avoid burnout
6. How to maintain relationships with patients over years
7. How to work efficiently and effectively with other specialists/generalists
8. The differences between acute care and chronic care
9. Explaining chronic versus acute care to patients

A lot of this you can pick up on your own with trial and error, tips and tricks from attendings, and good social skills–but it seems like it’s this gaping hole that medical training is de-emphasizing, even though it’s the bulk of “practicing medicine” as professional physicians.

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So I got pimped mercilously by my attending two days ago, while I was sick, feeling like crap, and had only seen my patient for like 20 minutes. So it never happens to you, I present the quick’n’dirty acid-base disorder step-by-step guide:

1. Get a blood gas. Put it in ice, send it to the lab.
2. Look at pH: Less than 7.4? Acidosis. Greater than 7.4? Alkalosis.
3. Look at pCO ₂ and bicarb. Do they move in the same direction as the pH, or the opposite direction? (Nl pCO ₂ = 40, nl bicarb = 24.) If they move in the sa ME direction, it’s primary ME tabolic. If they move in a diffe RE nt direction, it’s primary RE spiratory.
4. Is the non-primary system compenstating appropriately? (Calculate that with those annoying equations I can never remember.)
5. Is there an anion gap? (Na – Cl – bicarb > 12) If no, you’re done.
6. If yes, take the anion gap – 12. Add that to the bicarb level. If it’s greater than 26, you’ve got a metabolic alkalosis as well. If it’s less than 22, you’ve got a non-anion gap metabolic acidosis, too. Classic pimping: You can have 3 disorders co-existing, but not 4. (Your lungs can either be making respiratory acidosis or alkalosis, not both.)

And on to the mnemonics for the causes:

Anion Gap Metabolic Acidosis: MUDPILERS

• Methanol
• Uremia
• DKA/Alcoholic KA
• Paraldehyde
• Isoniazid
• Lactic Acidosis
• Etoh/Ethylene Glycol
• Rhabdo/Renal Failure
• Salicylates

Non-Anion Gap Acidosis: HARDUPS

• Hyperalimentation
• Acetazolamide
• Renal Tubular Acidosis
• Diarrhea
• Uretero-Pelvic Shunt
• Post-Hypocapnia
• Spironolactone

Acute Respiratory Acidosis (Chronic Respiratory Acidosis = COPD/restrictive lung dz): any hypoventilation state

• CNS Depression (drugs/CVA)
• Airway Obstruction
• Pneumonia
• Pulmonary Edema
• Hemo/Pneumothorax
• Myopathy

Metabolic Alkalosis: CLEVER PD

• Contraction
• Licorice*
• Endo: Conn’s/Cushing’s/Bartter’s)*
• Vomiting
• Excess Alkali*
• Refeeding Alkalosis*
• Post-hypercapnia
• Diuretics

* = Associated with High Urine Cl levels

Respiratory Alkalosis: CHAMPS (think speed up breathing)

• CNS disease
• Hypoxia
• Anxiety
• Mech Ventilators
• Progesterone
• Salicylates/Sepsis

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So I’m reading through this Wikipedia list of cognitive biases , and it’s pretty apparent that almost all of these factor in to our discussions of patient care. A sample, with the definitions provided by the Wikipedia:

• belief bias – the tendency to base assessments on personal beliefs (see also belief perseverance and Experimenter’s regress) All the time. We assume things about patients–what they do, how they act–based on our own understanding of “normal.”
• bias blind spot – the tendency not to compensate for one’s own cognitive biases. We don’t have to compensate. We’re the doctors; we’re right, duh.
• confirmation bias – the tendency to search for or interpret information in a way that confirms one’s preconceptions. Uh, pertinent positives and negatives? If I suspect cirrhosis, I’ll ask you about alcohol. And if you tell me you have 1-2 drinks a night, someone will say the “rule of doubling” so that you actually drink 2-4 drinks a night.
• disconfirmation bias – the tendency for people to extend critical scrutiny to information which contradicts their prior beliefs and accept uncritically information that is congruent with their prior beliefs. If I suggest someone might have HIV, someone usually says he or she “doesn’t have any HIV risk factors.” Translation: I think he or she is married or heterosexual, so they can’t possibly have HIV.
• endowment effect – the tendency for people to value something more as soon as they own it. If it’s lymphadenopathy, I don’t brag about my patient. But when it turns out to be fetus in fetu, I talk all about him.
• hyperbolic discounting – the tendency for people to have a stronger preference for more immediate payoffs relative to later payoffs, the closer to the present both payoffs are. Should we keep a patient or discharge her tonight? Discharge; it’s one less note to write in the morning.
• illusion of control – the tendency for human beings to believe they can control or at least influence outcomes which they clearly cannot. Oh boy. This just about sums up the physician mind.
• mere exposure effect – the tendency to express undue liking for things merely because they are familiar with them. “She’s just another CHF/COPD exacerbation.”
• planning fallacy – the tendency to underestimate task-completion times. “I’ll be right up to see the patient;” “He’ll be getting his CT at 2:30;” “The dictation should be online by tomorrow.”
• rosy retrospection – the tendency to rate past events more positively than they had actually rated them when the event occurred. “No, really, internship’s not that bad.” “This won’t hurt a bit, I had it done when I was your age.”
• selective perception – the tendency for expectations to affect perception. You label a person as “really nice,” and your team will probably think they’re nice. Label them as cranky or grouchy, and they’ll expect someone to be grouchy.
• status quo bias – the tendency for people to like things to stay relatively the same. We’re happy when the creatinine stays at baseline. We like uneventful hospital stays.
• Von Restorff effect – the tendency for an item that “stands out like a sore thumb” to be more likely to be remembered than other items. Attendings give anecdotal evidence: “During my residency I saw an Asian person with sarcoid, so it happens more often than you’d think!”
• Zeigarnik effect – the tendency for people to remember uncompleted or interrupted tasks better than completed ones. This is the intern’s defense mechanism. Everything gets done because you know you haven’t completed it yet, and no one else is going to do it for you.
• fundamental attribution error – the tendency for people to over-emphasize personality-based explanations for behaviors observed in others while under-emphasizing the role and power of situational influences on the same behavior. A person is over-emotional if they cry.
• ingroup bias – preferential treatment people give to whom they perceive to be members of their own groups. Hell yeah. If you say you’re Dr. So-And-So, you have a lot more clout that if you say, “I’m the medical student taking care of Ms. Jones.”
• self-serving bias – the tendency to claim more responsibility for successes than failures. It may also manifest itself as a tendency for people to evaluate ambiguous information in a way beneficial to their interests. “We really got her through that acute renal failure well” versus “She was really sick when she came in.”

Note: I’m not saying these happen all the time. Just that they can, and we’ve got to be on the lookout for them.

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My frustration continues to grow and grow with the more I work and work. I find it extraordinarily hard to believe that with all the great minds in computers and medicine, we don’t have a system that makes practicing medicine more quick and error proof. Even at the VA, a hospital system that has arguably the best computerized medical record, things ar incredibly inefficient.

An example of my day: get to the hospital, see my patients from the night before. Write down their labs from the computer onto a sheet of paper for my “progress note”–my assessment of what’s going on with them over the last day, if they have any new problems, and what I’m doing to diagnose and treat their problems. So I get their labs from the computer. Then I go to their chart, and write down their vital signs (temperature, blood pressure, pulse, breathing rate, O2 saturation) and Ins and Outs. Then I go to their nursing clipboard and write down their medications. Then I write out my assessment and plan for the patient (what I think each problem is caused by, and how I’m diagnosing/treating it).

Once this is all done, then I copy most of it to a little reference notecard, listing the patient’s recent labs, their ins and outs, and any changes or updates to their medications.

After all that, I present the patient to my attending, where I have to read aloud the vitals, the lab numbers, the changes in the lab numbers, any study results, and on, and on, and on.

An absolute, horrific disaster. A waste of time and paper.

I can imagine a system where we all have computers, or PDAs, and all our patients’ latest data just automatically appears. But it’s just a dream.

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You know, you’re in school for so long, for so many years when your papers or writings or assignments are only going to be read by your teacher. They’ll be skimmed or perused, commented on with red ink, and given a grade, but that’s the end of them. You get the paper back, maybe hold onto it for a bit, put it on the fridge for the family to see your gold star, but it ends there.

So sometimes I forget that my notes really do truly matter now. They’re no longer just going to be turned in to a professor or TA. They’re actually going to be used, and depended upon, for a number of people who are going to see a patient. They’re going to read my history and physical examination report, and then my assessment, and based on those, get a sense of what the patient’s problems are. It’s really different knowing that my notes matter. And by different I mean, “feeling like I’m contributing to the patient’s care, and also being kind of freaked out if I miss something or get something wrong.” I guess that’s why there’s interns, residents, and attendings double-checking me.

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So I’m watching this trailer for this documentary called “39 Pounds of Love,” , about a 42 year-old man with Spinal Muscular Atrophy Type 2 , whose doctor had predicted he would die by age 6. He’s now an animator, weighs 39 pounds, and goes in search of this doctor. From the trailer, I get the sense that he’s out to tell off the doctor for giving him such a grim prognosis. I don’t know if it’s how the story goes, but if it is, it surely isn’t fair.

As doctors, we’re in a predicament: taking away someone’s hope is, in my opinion, a mistake that I hope I never make, but probably will. At the same time, false hope is maybe worse. I try to remain cautiously optimistic, especially when things take a turn for the better. In fact, initial studies suggest that doctors are way too optimistic: one study found that doctors over-predicted prognosis by 5 times –so that in terminally-ill patients given, say, 10 months to live, they only lived about two.

This kind of makes sense–sunny-side up people are probably going to be more attracted to medicine than half-empty folks. Doctors like to imagine believe that we can truly fix every patient–or at least help them.

So especially in a condition as rare as Spinal Muscular Atrophy (4 cases per 100,000), especially back in the 1960s (there are 190 papers on it in Pubmed from 1900-1960, and only 40 in English), I don’t think the doctor was a bad doctor, or intentionally hopeless. If anything, if we believe the studies on prognostication, he was probably a little too optimistic.

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“Above all, do no harm,” is pretty much bullshit. Let me warn you.

You do not want to be a patient in a hospital. One, it means you’re sick enough to need to be in a hospital, which is pretty sick. Two, we’ll make you feel much worse until you feel much better. If you do get admitted, please just expect the following to happen. If you’re in a teaching hospital, with attendings and residents and medical students, more of this may happen. Be prepared in advance, so that you don’t get all crabby when I try to be happy-nice medical student and ask you some questions. (I realize you probably don’t mean to take it out on me, and that I’m always trying to put on my nice-happy face so that you won’t want to take it out on me, but you’re probably tired and frustrated and you’d take it out on Mother Teresa (may she rest in peace) if she were in my place, too.)

1. You will be poked and prodded, have your blood drawn–multiple times per day, from multiple arms and wrists.
2. You will tell your story to at least three people–not uncommonly 8 or more–and you will get annoyed, because we will ask you the exact same questions over and over again.
3. You will not get any sleep; people will constantly be bothering you with questions, physical exams, or lab draws.
4. You will be told lots of things, by lots of people, often things that use medical mumbo-jumbo. It will be confusing, probably–which test you’re getting, or what medicine you’re on. Many times people suck at explaining this stuff in normal terms, so please, please ask.
5. You may wet the bed, or defecate in your bed, and it may not be immediate that you get cleaned up.
6. You may be in a room with a noisy neighbor, or worse, a demented one that sits in a chair all day with her legs wide open and up in the air, making high-pitched shrieking noises all day.
7. You will probably smell, and when you do get washed up or get a sponge bath, it won’t be that fulfilling.
8. If you’re infected or contagious, people won’t want to touch you without gloves, and won’t enter a room with you without a mask. Necessary, but I’m sure isolating.
9. If someone decides you’re “an interesting case,” or you have something about your body that is different or rare or special, you may be made to feel like an object as a doctor teaches using you as an example.
10. Even if you’re not an interesting case, people may talk about your care with other team members like you’re not even there in the room, and many times, they will talk in medical code.

I’m not condoning this behavior or this system, but I’m saying often, it’s how it works. Many of the causes are medical–part of diagnosis or treatment–but others are political, legal, structural, academic, technologic and institutional in nature. We have a nursing shortage; we must teach future physicians; the law requires this; unions require that; paperwork must be done accordingly; technology is from the 1980s; there are limited resources available for health care. And on and on and on. If I could design the hospital system over again I would–and maybe I will when I’m older–but in 2006, this unfortunately may be your hospital experience.

Just more reason to stay healthy, eat well, exercise, and wash your hands, right?

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At the community hospital where I was working a couple months ago, a 10 second lullabye-type jingle plays over the intercom, signaling that a new baby has just been born. My attending says people either love the little reminder, or it drives them absolutely batty. I’m firmly planted on the side of the former. It reminds me that even if I’m busy, or tired, or frustrated waiting for a lab value to come back, at least someone has probably just become happy. That life goes on amidst all the hussle. Sometimes it’ll play twice. For twins.

And then I started wondering about a more solemn tone. Maybe it’s shorter, an elegant or graceful piano progression of chords, with a slower tempo. One recognizing that someone has just died. Now, granted, I think patients and doctors alike would get a little worried if it sounded 5 times within the hour–but I wonder how people would respond. Would it scare them? Upset them? Would they pause for a second? Think of their own mortality? Maybe it would remind them that life is short. And fragile.

But more than anything, I think it would upset them and scare them. Chime in here if you’re from another culture or tradition, but I think we as a society have some sort of obsession with youth–and some fear of death–that doesn’t exist in most other cultures. (I myself am utterly floored by the fact that I could (okay, fine, will ) die.) And what kind of ramifications does this have for medicine?

First let me note that there are two deaths I’m speaking of here: one inevitable, one failure, both tragic. One may seem like clinging on to scraps of ife because of our fears, and the other is truly medical failure. Everyone has to die of something , and I think most doctors want it to be something other than what they specialize in. But medical errors do exist–mismanagement, drug errors, etc.–and it’s those that we must fix. The scope of them is vast, and truly unacceptable.

The ultimate deaths, as I guess I’ll call them, are a harder sell. I absolutely respect people’s wishes, but I wonder how much of their wishes are influenced by our anti-aging culture. Are we guilty of trying to have as many breaths possible in our lives, at any cost? And how much of this worldview is cultural, and how much is just the human spirit? And yet I’m still torn, because our ability to prognosticate as doctors is so poor. You can take two patients, seemingly very similar, with similar diseases, risk factors, and prognoses, and see one make a fully recovery, and see the other wither away.

I just see too many people who are dying, of course in my opinion, poorly. If you want to die in an ICU, with tubes and machines and beeps and alarms, that’s your choice, but I think too often both patients and physicians see death as a failure of medicine, or as a failure of family members to make the right decisions for their loved ones. I think we’ll all face this issue more and more with the baby boomer generation, and I hope that more people will become aware of hospice care. Did you know 70% of people will die in a nursing home or hospital ? Take a moment to imagine your ideal death. Is it anywhere close to how people are dying today?

Who knows, maybe the progress is already happening, just happening at a medical (slow) pace. An attending today told the team, “Mr. Doe expired. He went home.” Initially we were very confused, but then she explained that with the patient’s last hours left, and no more medical treatments available, he went home to die, with his family at his side.

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Email was down, so if you emailed or commented, I didn’t get it. Sorry for that. I ask for your forgiveness. (I also ask for you to vote for me for best medical blog–I’m in the second half of the page.)

And just to know how my day went: One patient was hallucinating so much he thought he was eating a burrito; the other patient just started dialysis, had really bad abdominal gas cramps, and then looked at me and said, “Dude, I just pooped myself.” Ahh, medicine.

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