Carts passing in the night

I got called in last night to do an emergency echocardiogram. On the way down to the ER with echo machine, i got on the elevator with a gentleman from the food services department with a cart of late night snacks for patients -- as in one AM late night.

i struck up a conversation.

"We're both pushing carts at this hour...I didn't realize turkey sandwiches were in such demand this late at night."

"Yeah man, you wouldn't believe what people order at this hour... cottage cheese and pears... Trouble is, the nurses put in the order late, and half the time, the patient's asleep by the time they get their food," came the reply.

"Sounds like you and I are in the same line of work, this late at night," I said.

"No man, you guys are miracle workers man... The stuff you do is amazing."

"That's not quite true. People think we're always one step ahead, but actually, we're usually two steps behind... Just like you and that cottage cheese."

That resonated, and he chuckled knowingly. As the elevator door opened and I started pushing at the echo machine, he said, "treating but not curing, huh doc?"

The doors closed and I was left with that thought. We can cure some stuff, but in cardiology, we mostly treat and patients are left on medications for life. Wouldn't it be nice if we could get a jump on things like coronary artery disease and keep it from happening in the first place?

What Doctors Do

My wife and I just came back from visiting my brother- and sister-in-law (both physicians) and their children. It was time to leave, and we explained to their daughter (not yet four), that we had to go because we had to work tomorrow.

My sister-in-law asked her, "What do Kannan and Priscilla do? They do the same thing as Mommy and Daddy... remember we visited Daddy at work the other day? What does he do?" she prompted helpfully.

Without missing a beat, my niece said, "Sits on the computer!"

My three year-old niece already has a more realistic grasp of what a doctor's day is like then I had until my third year of medical school. Really. When I was a medical student, I was sure that most of the time doctors spent in hospitals was face-to-face with patients. I was very surprised to find this not to be true: most of the time a doctor spends in the hospital is spent with other doctors, nurses, charts, or indeed computers! In modern medicine, talk is literally cheap-- docs don't get paid much to do it. Rather docs get paid to do stuff to people. But wait, to get paid, you have to prove you did something. And to do that, you have to document. Documentation is also a good idea from a legal perspective. And it goes without saying that good documentation is good medicine -- patients benefit from having their story and their doctors ideas about their story clearly laid out in the record. But all of this means a lot of computer time.

I came across some interesting thoughts on the burden of documenting in a book entitled "The Young Doctor Thinks Out Loud." In it, the author Julian Price laments:

"...Right here we have one of the great nightmares of the intern's work--so-called 'paper-work.' I think that it is a conservative estimate to say that from ten to twenty-five per cent of the average inter's time on duty is spent in writing, depending upon the hospital and upon the conscientiousness of the young doctor. There is no more monotonous task that the writing of "histories and physicals." How often one feels that he is really not a physician, but just a stenographer..."

This was published in 1931. That's 75 years ago!

I guess things really haven't changed that much; we've just traded writer's cramp for carpal tunnel syndrome.

The mysterious land of OSH

Those of you who have looked at medical records, especially before the era of electronic "cut and paste" may be befuddled by the alphabet soup of acronyms that doctors use to communicate with one another -- that is, if you are not absolutely stupefied by the illegible handwriting first. A typical admission to a cardiology team might look like:

63 yo M c PMHx of DM, HTN, HL, +tob p/w CP x 20 mins c exertion, relieved c NTG.

In English, that's: A 63 year-old man with a past medical history of diabetes, high blood pressure, high cholesterol, and a smoking history presents with chest pain for twenty minutes with exertion, relieved by nitroglycerin tablets.

My favorite of these acronyms is OSH. This stands for "OutSide Hospital." No, not as in referring to something that happened oustide of the hospital, as one might logically infer, but as in another hospital that is outside the one you (the listener or reader) is currently in. Isn't that odd? A patient might have a cardiologist at OSH, as if the most important thing about the cardiologist is that he is not from "our hospital." A patient might have mitral regurgitation, but, we are quick to add, that is from an echo from an OSH.

This is not peculiar to Northwestern, I know. All my doctor friends at OSH use OSH too. What if you worked at Ohio State Hospital? OSH would get confusing for sure. I can just imagine rounds: "so wait, the echo was at our OSH or their OSH? gosh..."

What if in the news, we were to read "OS prime minister assassinated?" or "OS baseball team wins the World Series!!!" What if fourth graders' geography lessons in Chicago consisted of a map that had a dot labeled Chicago, surrounded by a big, fuzzy label that said OUTSIDE? (Well, with the way gradeschoolers test on things these days, maybe this is how it's actually done...)

If we didn't enrich our lives with actually knowing something about somewhere else beside where we are, wouldn't we be poorer for it?

You might think the OSH phenomenon means doctors are snobs, and devalue the work of other doctors. I don't think that's exactly right. What I think it reflects is what experienced doctors know, and what I am beginning to learn: in medical tests and diagnoses, to paraphrase Churchill, there are nuances on top of subtleties inside variations. A written report from OSH, though OSH be the Mayo Clinic, can ony carry so much weight with it. The report can't tell you the worried look on the face of the radiologist when he writes "must consider volvulus." The report can't tell you the severity of mitral regurgitation the way looking at it with your own eyes will. The report can't convey any of our colleagues' intuitions that we rely on to navigate our patients through illness to health.

So when we say OSH, I think we mean to say OSMCZ: outside my comfort zone. I think we are really saying that a piece of data is out of the context we are used to, and therefore we aren't really as sure what to do with it. But since OSMCZ is all but impossible to pronounce, outside (there it is again!) perhaps Eastern Europe, I will CPM & cont c OSH (continue present management, and continue with 'outside hospital').

My blog persona and patient confidentiality

Well, it's been about two weeks since I started blogging. I'm still blogging. I guess that means I have the bug, and I am hopefully infected for the long term, rather than transiently.

Thank you to everyone so far who has been reading my blog and leaving comments! I am humbled by the notion that some people actually find what I have to say worth reading. It's not great literature--but hey, one of the reasons why I started to blog is that I figured it would improve my writing.

One issue I am struggling with is that I want to share stories about things that happen in the hospital, but I want to respect patient confidentiality even more. Because I am completely open about who I am in the real world,meeting both of these goals seems near impossible.

I can't really write about specific patient encounters as they happen, because that would make patients readily identifiable. For example, how many patients really come through the Northwestern emergency room with, say, a long QT-interval resulting in Torsade de Pointes (a specific, whimsically named type of arrhythmia)? I can tell you not many. (By the way, if you have, I assure you it is complete coincidence!)

If such a patient did come through the ER, and I blogged about it that day, he or she would be readily identifiable. Maybe if I changed things around enough, the only person who would know would be the patient himself. But I still think that person would feel that their confidentiality was breached-- if not by the letter of the law, then certainly by the spirit. If a patient of mine ever figured out that I was blogging specifically about him or her, I would feel terrible. I strongly feel that a patient's medical story is their business alone, and it is up to them to choose whom to share it with.

But at the same time, I think specific encounters with real people breathe life into stories. These are stories that involve some of the most fundamental experiences a person can have, experiences that transcend culture, experiences that transcend time itself. A family deciding to let a loved one go is something that can be appreciated here or in China. It can be appreciated now, a thousand years ago, or a thousand years from now. I really think these stories with patients are worth writing.

Trouble is, I haven't figured out how. Any suggestions?

Opting out of the AMA database

I found this post by California Medicine Man to be fascinating. It is regarding how the American Medical Association makes physicians' prescribing information available to pharaceutical representatives, and how physicians can opt-out of this, er... sort of.

Clopidogrel (Plavix) generic in the future?

I just came across this article
in the New York Times, but I guess it is from a few days ago. It is regarding a generic version of clopidogrel, or Plavix. I had no idea there was a patent dispute involving the drug, but I guess there is. Sounds like an alternative manufacturer shipped in a whole bunch of the drug, but isn't allowed to ship in any more, and now there is an extra 3 months' supply on the U.S. market!

All I know is that Plavix = Big Business. Actually, BIG BUSINESS. Anyone who leaves the hospital with a stent these days is put on Plavix. For a month if it is a "bare metal stent," and for at least three to six months if it is a "drug-coated" stent. And, there is some thought that maybe it's better to have people on Plavix for a year after they get a drug-coated stent.