It was a good book, but I think it fell short of my expectations after seeing on the cover that it was a National Book of the Year Finalist. The beginning was great, the end really had me turning the pages to see if the case was a zebra or a horse, but the middle seemed to simply contain filler material: Friday the 13th?, rare and idiopathic cases? I guess to me they didn't really fit the title of the book.
The topics you have brought up for discussion have been interesting to consider from the viewpoint of a veterinarian, especially the idea of death panels and "doctorly manipulation".
The first several months that I was in practice I kept a tally of all of the animals that I euthanized, kind of like a fighter pilot might keep a running tally of the enemy planes he shot down. I know that might sound bizarre or morbid, but I guess that was my crazy way of dealing with a very emotionally difficult part of the profession. I have a friend who wanted to be a veterinarian, but she couldn't handle the idea of "putting an animal to sleep." She is now a human anesthesiologist. Ah, the irony.
Related to dealing with euthanasia is the art of "doctorly manipulation." It is amazing how attached people can become to their pets, and yet how removed they can be of the reality of animal suffering. I believe it is often a case of denial. Deep down they know that their cat that is in terminal renal failure is wasting away and is suffering because of it, but they dread letting go of what is more a companion than a pet. And so it is the veterinarian's responsibility to open the eyes of the client. It is a very difficult dance of tactful discussion. Just as difficult are the conversations where there is a treatment available for a patient, but the client is not able to afford the treatment.
On the topic of misdiagnosis and inexperienced physician, I feel that has my name written all over it. There are internships and residencies available to veterinarians, and it is becoming more common for graduating a graduating veterinarian to pursue some area of specialization, but there are still many who go right out on their own after getting their diploma. Such was my route. I remember my first day on the job, I had passed my board exams, but my license had not yet arrived in the mail. I showed up to work a little early in order to make a good impression and make a few preparations for the day. None of the other veterinarians were there yet, so when one of the employees brought in her cat that had been attacked by a dog just before leaving for work, it was to me that she handed the animal. It is hard to put into words the feeling of inadequacy as she looked to me as THE veterinarian that would save her cat. Fortunately it wasn't too bad. I placed an IV catheter help stabilize the animal, and we cleaned up some of its wounds as we waited for the other doctors to show up for the day.
There were other moments where I didn't feel completely up to the task, but I did my best. With difficult cases, referral to a specialist in a neighboring city, wasn't much of an option because of financial restrictions or because of the distance to the specialist. I would sometimes purposefully leave my pen at my desk, so that when I was in the exam room and had little clue as to what I was dealing with, I would go to make a note in the patient's record and then tell the client, "Just a moment, I need to go get my pen," allowing me a couple of minutes to quickly look through one of the medical texts in the office. Another "trick" that I picked up in vet school: one of my professors was faced with a sick cow that required an operation that he had been taught, but had never performed. Just before he began the client asked, "Have you done this kinda thing before?" To which the vet replied, "Oh, I've done a number of them." After relating that story to us during a lecture, the professor grinned and said, "Zero is a number."
I surprised me how forgiving clients could be about my lack of experience. I believe that they understood the challenge in diagnosing a case where the patient can't talk and the resources are limited. I don't feel too much shame in admitting, "I don't know," because most clients don't expect the vet to know everything about every species of animal. Sometimes we have to figure it out as we go. There's a reason we call it "practicing medicine."
Wow, I can't believe how much I have rambled on here. Just one quote from the book before I end this post.
"Conscious learning becomes unconscious knowledge, and you cannot say precisely how." pg 21
Saturday, December 26, 2009
Tuesday, December 22, 2009
2 follow-on comments on Complications
Thanks for all the great discussion on "Complications." Two follow-on points:
Peter - regarding checklists: I am absolutely a proponent of using checklists in medicine. I'm a doctor now, but I was an engineer first. When using humans to perform a task, you improve performance by putting in systems to minimize variation. Intel was great at this; whenever someone made a mistake, our first question was "is this something that could have been prevented by a systems improvement?" This did add sometimes cumbersome layers to a task, but results at Intel are phenomenal.
Back to medicine, this applies directly to Radiology. It can be crucial to have a pre-determined way to approach any given examination. We frequently fall victim to the "satisfaction of search," where a prominent positive finding prevents us from noticing the more subtle abnormalities in a study. Time after time in our M&M conferences, a missed diagnosis comes down to "I guess I just failed to look for _____." I believe that in reviewing a given type of radiology study, the radiologist should take precisely the same steps. I read recently about a hospital (Michigan) who improved radiology reporting by having pre-determined templates for all reports -- basically a checklist of "I checked this, and is was normal, I checked this, and it was abnormal." Many radiologists prefer to dictate their own personalized report, but the standardized report ensures that everything is looked at and reported.
Alvin - Regarding "Death Panels": Actually Becky is the one who came up with this recommendation. A good place to start would be requiring individuals to generate their living will and health care power of attorney documents in order to enroll in Medicare. This would have no effect on many patients, but does take the burden of decision off of the families who find themselves extending care because they don't know what's best for mom or dad, and don't want the burden of having "pulled the plug." And we do see living wills that say "any and all care" on them. Those are fine, too.
Friday, December 18, 2009
Less Complicated and More Anecdotal
In some ways, I think structural engineering and medicine are similar, If we make a mistake, people can die. I like to think that because of that, I have to do a good job. I know, doctors get all the glory, the fame, the TV shows, etc., but the hospitals they work in are designed with importance factors and stuff that makes their work environment safe--so that when other buildings collapse and people get hurt, the ER will be open and ready to help them.
Misdiagnosis
Because the likelihood for misdiagnosis seems to be more likely if the physician has less experience, this means, like many professions, that I want to choose the most experienced physician for what I'm dealing with. Personally, I've been frustrated by the young Physicians Assistants that we have seen that we've had to guide along to the correct diagnosis. I do find comfort in older doctors because it seems like they've seen it all. Surgeons—even more so. I want the guy who does 1000 operations a year as opposed to someone who occasionally does them. I think surgeons are generally aware of their capabilities and I'm glad for that. As an engineer, if I'm not capable of doing something, I recommend that the client uses someone else that can do the job properly. I know when my dad (an eye surgeon) saw a case he wasn't sure about, he'd send them to someone who would be.
Doctorly Manipulation:
“There are times when a doctor has to steer patients to do what's right for themselves.” and “Patients don't want the freedom we've given them.” I agree. I think it's often quite silly to give patients freedom. Again, as an engineer, if I say structure needs to be there, it needs to be there. If it isn't, when the office has a party and people dance where the structure isn't, they'll fall to their deaths (Hyatt Regency catwalk collapse). When I meet with a client who doesn't want the structure, I tell them they need it. I expect a doctor, usually more expert than me in medicine, to tell me when I need something. For example, we had a breech baby last time, and the doctor said, “we're going to do an ECV [turning the baby] and then induce”. My wife said, “well, we were thinking about doing the ECV and then letting the baby come naturally.” The doctor said, “ok” and would have let it end at that. But after asking him some more questions, we chose to do exactly what he initially recommended, and it was a good thing too.
I enjoyed the book very much. Thanks Doug.
Misdiagnosis
Because the likelihood for misdiagnosis seems to be more likely if the physician has less experience, this means, like many professions, that I want to choose the most experienced physician for what I'm dealing with. Personally, I've been frustrated by the young Physicians Assistants that we have seen that we've had to guide along to the correct diagnosis. I do find comfort in older doctors because it seems like they've seen it all. Surgeons—even more so. I want the guy who does 1000 operations a year as opposed to someone who occasionally does them. I think surgeons are generally aware of their capabilities and I'm glad for that. As an engineer, if I'm not capable of doing something, I recommend that the client uses someone else that can do the job properly. I know when my dad (an eye surgeon) saw a case he wasn't sure about, he'd send them to someone who would be.
Doctorly Manipulation:
“There are times when a doctor has to steer patients to do what's right for themselves.” and “Patients don't want the freedom we've given them.” I agree. I think it's often quite silly to give patients freedom. Again, as an engineer, if I say structure needs to be there, it needs to be there. If it isn't, when the office has a party and people dance where the structure isn't, they'll fall to their deaths (Hyatt Regency catwalk collapse). When I meet with a client who doesn't want the structure, I tell them they need it. I expect a doctor, usually more expert than me in medicine, to tell me when I need something. For example, we had a breech baby last time, and the doctor said, “we're going to do an ECV [turning the baby] and then induce”. My wife said, “well, we were thinking about doing the ECV and then letting the baby come naturally.” The doctor said, “ok” and would have let it end at that. But after asking him some more questions, we chose to do exactly what he initially recommended, and it was a good thing too.
I enjoyed the book very much. Thanks Doug.
The road, the man, and life
Some belated thoughts on the road:
I listened to this while on the road from Vegas to SLC. It was a dreary day, and the landscape through Nevada is very post-apocalyptic. Then the whole family got sick. I had a temporarily deep voice, and found myself talking like the narrator's voice for the man.
I listened to this while on the road from Vegas to SLC. It was a dreary day, and the landscape through Nevada is very post-apocalyptic. Then the whole family got sick. I had a temporarily deep voice, and found myself talking like the narrator's voice for the man.
It made me think how even in the face of death (you ARE dying), we strive to live. Why? I don't think it's the fear of death—I'm not really scared of death, but I do want to live. Mostly because I enjoy life. I don't know if I would have this same desire if life weren't enjoyable. Because I really believe the next life is a continuation of this, often I find myself thinking, "oh, it would be okay if I died." I'm sure I would feel differently if I were the only source of protection for my children. It seemed the man had a stronger desire to live. It sure wasn't for himself, it was definitely to take care of the boy.
But the movie looks too scary for me.
Sunday, December 13, 2009
Why'd You Have To Go And Make Things So Complicated?
Church was cancelled today due to icy conditions at 7 AM that were fine by the time church starts at 11, but it gives me some time to write. I really enjoyed the book Complications and Doug's thoughts. I will just add my comments on the topics Doug put out there.
1. The uncertainty in medicine - I enjoyed how the book portrays doctors as human, whereas we often give them superhuman powers in our minds. As Peter points out, we also do this with General Authorities, and to a lesser degree, I also catch myself doing this with car mechanics, reality TV stars, and politicians.
Before the US went to war in Iraq, I supported the action under the assumption that President Bush knew something that I didn't, something top secret that he just couldn't share with me. Similarly, I often assume that General Authorities know more than I do or have seen something that I haven't and thus they have more power to be spiritual. I thought plumbers knew more than I do, too, that I could never change a sink, until it was pointed out to me that they don't have advanced degrees. They just have more experience and the right tools. It's empowering to realize that I have just as much power and ability to do all of these things, IF I apply myself to learn the relevant skills and use the right tools (or if I invite Glenn over to help me change the sink).
2. Autonomy, consent, and the role of the patient - I have very conflicting feelings on this point. I believe that, as described by Gawande and Doug, patients often make very poor decisions, and particularly at the end of life, a lot of resources are wasted. Survival at all costs is not necessarily best for the community or the patient. Unfortunately, the only solution to this seems to be the dreaded 'Death Panels'.
As I read this book, I often thought about how the roles of doctors and patients compare to the roles of parents and children. Children often don't realize how human their parents are and how much uncertainty there is in what we do. And children may often make poor decisions, but after a certain age all parents can do is offer advice. Right now, my children are so young that my word is the law, but eventually, I'll have to grant them their agency and allow them to make poor choices, even if it's a waste of resources.
3. Top performers and practicing - That really is a great quote. I think Malcolm Gladwell (who was quoted on the book jacket of my copy of Complications) says something similar in his more recent book, Outliers. I think both Gladwell and Gawande are lucid, interesting writers.
4. Learning on the job - There is a lot of learning on the job and uncertainty in my profession, too, but the big difference is that I don't have a direct impact on the life or death of another person. (I may have an indirect impact in the approval or disapproval of a medical device, but I don't have to face them directly.) There may be mistakes in the learning process, but I don't see how the medical profession could do it any other way.
Speaking of my profession, though, I was happy to see that Gawande's attempt to use Decision Analysis didn't work because I think it's a bunch of bunk. It makes the process of arbitrarily assigning probabilities to different events seem scientific, when it's not. My boss is trying to get the FDA to use Decision Analysis on a wide scale, and I'm avoiding the meetings and hoping the movement dies quickly. I do believe that statistics has and will continue to help improve medical decision making, just not though Decision Analysis.
5. Medical errors and liability suits - I keep reading in multiple books how poor the litigation system is in preventing doctors from making mistakes. The worst doctors don't have the most lawsuits, and the best doctors still make mistakes. In the book, "Nudge", the authors suggest that people should be able to waive their right to sue in order to get lower insurance premiums, but the courts and lawmakers for some reason don't think that people should be allowed to waive their rights to sue.
1. The uncertainty in medicine - I enjoyed how the book portrays doctors as human, whereas we often give them superhuman powers in our minds. As Peter points out, we also do this with General Authorities, and to a lesser degree, I also catch myself doing this with car mechanics, reality TV stars, and politicians.
Before the US went to war in Iraq, I supported the action under the assumption that President Bush knew something that I didn't, something top secret that he just couldn't share with me. Similarly, I often assume that General Authorities know more than I do or have seen something that I haven't and thus they have more power to be spiritual. I thought plumbers knew more than I do, too, that I could never change a sink, until it was pointed out to me that they don't have advanced degrees. They just have more experience and the right tools. It's empowering to realize that I have just as much power and ability to do all of these things, IF I apply myself to learn the relevant skills and use the right tools (or if I invite Glenn over to help me change the sink).
2. Autonomy, consent, and the role of the patient - I have very conflicting feelings on this point. I believe that, as described by Gawande and Doug, patients often make very poor decisions, and particularly at the end of life, a lot of resources are wasted. Survival at all costs is not necessarily best for the community or the patient. Unfortunately, the only solution to this seems to be the dreaded 'Death Panels'.
As I read this book, I often thought about how the roles of doctors and patients compare to the roles of parents and children. Children often don't realize how human their parents are and how much uncertainty there is in what we do. And children may often make poor decisions, but after a certain age all parents can do is offer advice. Right now, my children are so young that my word is the law, but eventually, I'll have to grant them their agency and allow them to make poor choices, even if it's a waste of resources.
3. Top performers and practicing - That really is a great quote. I think Malcolm Gladwell (who was quoted on the book jacket of my copy of Complications) says something similar in his more recent book, Outliers. I think both Gladwell and Gawande are lucid, interesting writers.
4. Learning on the job - There is a lot of learning on the job and uncertainty in my profession, too, but the big difference is that I don't have a direct impact on the life or death of another person. (I may have an indirect impact in the approval or disapproval of a medical device, but I don't have to face them directly.) There may be mistakes in the learning process, but I don't see how the medical profession could do it any other way.
Speaking of my profession, though, I was happy to see that Gawande's attempt to use Decision Analysis didn't work because I think it's a bunch of bunk. It makes the process of arbitrarily assigning probabilities to different events seem scientific, when it's not. My boss is trying to get the FDA to use Decision Analysis on a wide scale, and I'm avoiding the meetings and hoping the movement dies quickly. I do believe that statistics has and will continue to help improve medical decision making, just not though Decision Analysis.
5. Medical errors and liability suits - I keep reading in multiple books how poor the litigation system is in preventing doctors from making mistakes. The worst doctors don't have the most lawsuits, and the best doctors still make mistakes. In the book, "Nudge", the authors suggest that people should be able to waive their right to sue in order to get lower insurance premiums, but the courts and lawmakers for some reason don't think that people should be allowed to waive their rights to sue.
This is the issue that drives me the most crazy about the whole health care debate. If Democrats are truly serious about reducing the cost of health care, then putting a cap on the amount people can sue for seems like an easy way to start (the studies on this issue seem pretty unambiguous), but this issue hasn't even been part of the debate. It just makes me think that Democrats aren't really trying to help fix health care, that it's just politics as usual. (Note: On a broader note, I'm open to universal health care, though I'm skeptical of the government's ability to efficiently distribute health benefits.)
6. The man who couldn't stop eating - Doug says, "If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves?" I guess I'm more sympathetic than Doug to those that are not self-disciplined. I have a compulsion to play games/waste time when I should be working on my unfinished PhD research. Having tried and failed to change myself multiple times, you begin to stop trusting yourself when you say things are going to be different this time. If there were a surgical option such that I could get myself to always do what I thought was right, I would seriously consider it. (Of course, that may be Satanic of me to want to force myself to do good.)
6. The man who couldn't stop eating - Doug says, "If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves?" I guess I'm more sympathetic than Doug to those that are not self-disciplined. I have a compulsion to play games/waste time when I should be working on my unfinished PhD research. Having tried and failed to change myself multiple times, you begin to stop trusting yourself when you say things are going to be different this time. If there were a surgical option such that I could get myself to always do what I thought was right, I would seriously consider it. (Of course, that may be Satanic of me to want to force myself to do good.)
And like the blushing example he gave, sometimes what outsiders perceive as a need to be more mentally disciplined is something rooted in a physical problem. Maybe we weren't born messed up, but perhaps the learned behaviors in childhood become hard-wired. I agree that as a society we are fat and lazy, as Doug said, and admittedly, whenever I see a morbidly obese person (there's one at work) I shudder and think, "Get a grip, Man!" Still, on paper, I'm hesitant to judge anyone too harshly.
Again, thanks Doug for the good read. I look forward to hearing everyone's comments.
Monday, December 7, 2009
Making a list, checking it twice...
I really enjoyed Gawande's book. I may read his follow-up Better: A Surgeon's Notes on Performance.
I agree with Doug that the central theme of the book is the essential human-ness of medicine, even surgical medicine. I have a couple thoughts on that front:
First, although Gawande talks about the dramatic improvement in mortality numbers among anesthesiologists, he doesn't to my recollection mention safety checklists (which is a bit odd, since Gawande has been a vocal advocate of such checklists; maybe he came to it after writing the book).
I was wondering what you think of checklists, Doug? My impression (and its nothing more than that) is that most surgeons view them as a hassle, something that is nice in theory but lousy in practice, not worth the effort, etc. And understandably so; I know the highly formalized type of check-list activities I do for work are an annoyance.
But I think the bigger issue is that perhaps doctors feel it is juvenilizing to have to run the checklist, that pride or ego maybe gets in the way. And not just for individual doctors, but sociologically within the subculture, making it difficult even for doctors who wouldn't mind running a checklist before surgery to do so in the face of colleague disapproval. I don't know; maybe all this is off-base, constructed more from fictionalized views of medicine than reality, but if it is reality I think it's a very understandable one, and one that fits with Gawande's larger narrative.
Second, I was talking with a ward member the other day about the book. Her husband is starting a two-year internship in pediatric radiology at Children's hospital in Boston. I wondered whether Americans have a tendancy to mythologize Doctors more than other cultures do, and thus have less tolerance for the human element of medicine. She said that she certainly feels that to be the case. She said she feels exactly the same sort of mistaken expectations when she tells people that her husband is a surgeon as when she tells people that her father-in-law is a General Authority.
I think we do mythologize doctors, and I think Gawande would like to temper that to some degree, and I think it is healthy to do so. I also think, however, that doctors (and society in general) also receive some benefits from that mythologizing inclination. Specifically, I think people are more likely to trust and have faith in doctors than they otherwise might. This goes to the patient autonomy question, I suppose. As Doug says, in some ways patients are terrible decision makers when it comes to their treatment options. Given the trend toward patient autonomy, eroding the myth of The Doctor could lead to even worse decisions on the part of the patient as they come to see doctors more and more as imperfect, fallible human beings. Perhaps this is why Gawande calls for a move back to the old model of doctors largely deciding what is in the patient's best interest.
One thing that Gawande didn't talk about that I think is particularly timely is the intersection of medicine and public policy. I was recently chatting with a friend who is an Air Force doctor. He went on at some length about the ways in which specialization is increasing, how it is driving policy more and more, and how general practioners are getting squeezed out as a result. His statement, if I remember correctly, is that because the Medicare advisory board is dominated by specialists, they are able to set rates that they feel are appropriate, which means the finite pot of money is increasingly split up with a bias toward recompensing specialists. This has echoes in the health care debate today as they talk about different payment models, like paying per positive patient outcome rather than per procedure. Anyway, not really on topic but something I find fascinating.
Thanks for the great read, Doug.
We've now reached the end of the second book club round. I think we should all take December off and start up again with a January selection. Anyone not on the following list who would like to make a selection, let me know either in the comments or via email: Peter, Alvin, Paul, Glenn, Rob, Doug, Jesse, Karl (Jesse and Karl, I know you've been quite busy with other things and haven't followed along with the book club this round. But if you have time I'd love to keep you in as making one selection, even if that's the only month in which you're able to participate. If you don't feel like you can do that, just let me know and we'll skip you this time around).
I'll give it until next week sometime for anyone who wants to to amend the list, then I'll use my patented, handy-dandy randomegizer to choose an order for the participants.
I agree with Doug that the central theme of the book is the essential human-ness of medicine, even surgical medicine. I have a couple thoughts on that front:
First, although Gawande talks about the dramatic improvement in mortality numbers among anesthesiologists, he doesn't to my recollection mention safety checklists (which is a bit odd, since Gawande has been a vocal advocate of such checklists; maybe he came to it after writing the book).
I was wondering what you think of checklists, Doug? My impression (and its nothing more than that) is that most surgeons view them as a hassle, something that is nice in theory but lousy in practice, not worth the effort, etc. And understandably so; I know the highly formalized type of check-list activities I do for work are an annoyance.
But I think the bigger issue is that perhaps doctors feel it is juvenilizing to have to run the checklist, that pride or ego maybe gets in the way. And not just for individual doctors, but sociologically within the subculture, making it difficult even for doctors who wouldn't mind running a checklist before surgery to do so in the face of colleague disapproval. I don't know; maybe all this is off-base, constructed more from fictionalized views of medicine than reality, but if it is reality I think it's a very understandable one, and one that fits with Gawande's larger narrative.
Second, I was talking with a ward member the other day about the book. Her husband is starting a two-year internship in pediatric radiology at Children's hospital in Boston. I wondered whether Americans have a tendancy to mythologize Doctors more than other cultures do, and thus have less tolerance for the human element of medicine. She said that she certainly feels that to be the case. She said she feels exactly the same sort of mistaken expectations when she tells people that her husband is a surgeon as when she tells people that her father-in-law is a General Authority.
I think we do mythologize doctors, and I think Gawande would like to temper that to some degree, and I think it is healthy to do so. I also think, however, that doctors (and society in general) also receive some benefits from that mythologizing inclination. Specifically, I think people are more likely to trust and have faith in doctors than they otherwise might. This goes to the patient autonomy question, I suppose. As Doug says, in some ways patients are terrible decision makers when it comes to their treatment options. Given the trend toward patient autonomy, eroding the myth of The Doctor could lead to even worse decisions on the part of the patient as they come to see doctors more and more as imperfect, fallible human beings. Perhaps this is why Gawande calls for a move back to the old model of doctors largely deciding what is in the patient's best interest.
One thing that Gawande didn't talk about that I think is particularly timely is the intersection of medicine and public policy. I was recently chatting with a friend who is an Air Force doctor. He went on at some length about the ways in which specialization is increasing, how it is driving policy more and more, and how general practioners are getting squeezed out as a result. His statement, if I remember correctly, is that because the Medicare advisory board is dominated by specialists, they are able to set rates that they feel are appropriate, which means the finite pot of money is increasingly split up with a bias toward recompensing specialists. This has echoes in the health care debate today as they talk about different payment models, like paying per positive patient outcome rather than per procedure. Anyway, not really on topic but something I find fascinating.
Thanks for the great read, Doug.
We've now reached the end of the second book club round. I think we should all take December off and start up again with a January selection. Anyone not on the following list who would like to make a selection, let me know either in the comments or via email: Peter, Alvin, Paul, Glenn, Rob, Doug, Jesse, Karl (Jesse and Karl, I know you've been quite busy with other things and haven't followed along with the book club this round. But if you have time I'd love to keep you in as making one selection, even if that's the only month in which you're able to participate. If you don't feel like you can do that, just let me know and we'll skip you this time around).
I'll give it until next week sometime for anyone who wants to to amend the list, then I'll use my patented, handy-dandy randomegizer to choose an order for the participants.
Wednesday, December 2, 2009
Glenn's thoughts on Millet's book
I really enjoyed the posts from you guys. I considered your comments and had drafted some responses to them, but that draft disappeared. If I find it someday I may post it. For now I will share with you things that I took note of during the first part of the book. Before I do so, let me just say that I was surprised when I started into the book, how general and broadly applicable the ideas were. I was expected Bro. Millet to say, "Now, when you get asked this by your non-member co-worker, this is what you should say." It's true that the book does contain some of that in later chapters, some of which I found interesting, some of which I have already forgotten. The most useful thing in the book, in my opinion, is that he suggests how to answer a question rather than trying to give us a script to use when answering a question. Teach them correct principles ...
Here are some quotes about faith and testimony that resonate with me, and are of value to me, especially since burying myself in research:
"A testimony is not something you either have or do not have. Rather, it is an impression of the Spirit about the truthfulness of eternal things, an inner awareness that ranges along a spiritual continuum from a simple peaceful feeling to a perfect knowledge" - pg 30
"I believe because of the epiphanies, small and large, that have intersected my path -- small discrete moments of grace when I have sensed a kind of superinteding presence outside of myself. I believe because these moments ... are too precious to discard, and I choose not to trivialize them by reducing them to rational explanation. I believe because, for me, the alternative to belief is far too daunting." - pg 34
I finished Complications this morning. I will read through Doug's post and try to get something equally worthwhile up here soon.
Here are some quotes about faith and testimony that resonate with me, and are of value to me, especially since burying myself in research:
"A testimony is not something you either have or do not have. Rather, it is an impression of the Spirit about the truthfulness of eternal things, an inner awareness that ranges along a spiritual continuum from a simple peaceful feeling to a perfect knowledge" - pg 30
"I believe because of the epiphanies, small and large, that have intersected my path -- small discrete moments of grace when I have sensed a kind of superinteding presence outside of myself. I believe because these moments ... are too precious to discard, and I choose not to trivialize them by reducing them to rational explanation. I believe because, for me, the alternative to belief is far too daunting." - pg 34
I finished Complications this morning. I will read through Doug's post and try to get something equally worthwhile up here soon.
Tuesday, December 1, 2009
Complications
November's book: Complications, A Surgeon's Notes on an Imperfect Science
The first time I read this book I was pretty early in my medical training. It was fun to read it again after a few years, this time with a much different perspective. I have been there for many of the scenarios that Gawande describes, being as he was a resident. Anyway, I have my own medical opinion of what he has produced. I am interested to know how the rest of you felt about the points he made. Here are some topics of discussion, with my thoughts:
1)"The core predicament of medicine -- the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing -- is uncertainty." (pg 229)
---This seems to be the theme of the entire book. Other than the "mystery" chapters where he details some rare and bizarre conditions, Gawande mostly seems to be explaining just how human modern medicine really is. In spite of all the advances of science, medicine comes down to a fallible doctor in a room with a patient -- and several unknowns.
Personally, I tend to agree. I of course have been working rather diligently (happy birthday, Alvin) for the past several years to learn things most people don't know. I think it's safe to say that I'm better than the rest of you at being a doctor. But in the end, I'm not really perfect at this -- nor will I ever be. I'm basicaly the guy with a competetive advantage for this field.
I remember prior to my mission, I thought there were people who spoke French and people who didn't. It was incredibly naive, but there it is. I remember listening to my MTC instructors use the language so freely, and I did my best to copy them. Even after I got to the country, I thought the more experienced elders were using perfect French. Only with time and experience (and actually a lot of dedicated study) could I recognize that probably 2/3 of the missionaries were finishing their mission with sub-standard French, and markedly American accents.
I think much of America has the naive thinking I used to have about language ability: "A board-certified physician is qualified to be my doctor." In reality, there are widely disparate levels of ability, care, and dedication - to say nothing of the unknowns we encounter no matter our ability. Back when I got into medical school, there were several people who advised me to work hard but not too hard -- "What do they call the guy who gets last place in his medical school class? . . . Doctor." That may be true, but the title only means so much. This goes to the malpractice comment later, but people expect doctors and medicine to behave like a robot and a factory. It's not that easy. "We look for medicine to be an orderly field of knowledge and procedure. But it is not." (page 7)
2) Autonomy, consent, and the role of the patient.
"The decision was Lazaroff's." (pg 210)
"Could it have been a mistake, then, even to have told him about the surgical option?" (pg 216)
"patients frequently don't want the freedom that we've given them." (pg 219)
---I'm curious how you feel about today's world of patient autonomy and informed consent. This idea, that the patient should approve all medical decisions, is strictly taught in our medical schools. It's one of the basic tenets of ethical medical practice -- as much as beneficence and nonmalfeasance. I personally met with about 30 patients yesterday to have them sign "informed consent" paperwork for interventional radiology procedures. The basic principle is that the patient must be of sound mind and aware of the risks, benefits, and alternatives of a procedure before allowing the doctors to proceed.
This all sounds great on paper, or in a courtroom. But personally I don't really like it. I essentially walk into room after room and say (not really here, folks; I'm using hyperbole to make a point...) "Mrs So-and-so, your doctor has asked us to place a stent in your liver. I'm going to ask you to sign a sheet that says we might kill you, but that you want us to proceed anyway. Of course we never try to kill people in our department, but there's always that one you didn't see coming..." That way, when the patient does die, we can point to our document as protection.
But only in extremely rare cases does the patient grasp what may or may not happen on our table today. And almost nobody can objectively detach themselves from the numbers. I can tell patients the odds that we'll cause internal bleeding, infection, and even death. Still, it almost never means they understand the best course of action. In the end, I get two types of people. 1- the patients who look at me with a carefree smile and say "where do I sign?" and 2- the patients who are shocked by all the complications I am forced to mention and sign with "if you really think this is the best thing for me." Interestingly, I have never personally encountered a patient who refused consent for a medical procedure that was recommended by their physician.
OK so there are some patients who are crazy and who refuse consent, but I mean normal people.
So I'm not saying that we should hide facts and decisions from patients. I do believe our current "autonomy" and "informed consent" framework is built around lawsuit protection rather than patient care. I think a more reasonable approach is to discuss the procedure with the patient, in as much detail as they desire, leaving the words "cardiac arrest," "brain injury," "loss of life," and others out of the discussion.
One other (very real today) problem with the "Patient Autonomy" movement is cost. We let patients dictate how much care they do or do not receive.
Wait... pause... My personal code of ethics and even religion are going to come out in this paragraph. Just bear that in mind; I would not and cannot force my feelings on someone else.
Where was I? We are all going to die. All of us. And experienced doctors can tell when you are on your way out. Almost universally, though, we don't recommend stopping care. We sugar coat things and give patients (or families) the sense that there is a better chance of recovery than there really is. So we talk to patients or their families about these expensive and likely futile options, again having the informed consent discussion. We basically leave it up to them if we continue "agressive" care or not. My experience is that almost no one can choose to give up. Either the patient doesn't want to give up(naturally), or the family doesn't want to live with the burden of "not having done everything we could." So the medical costs in the last year of life skyrocket.
Enough about that...
3) "Top performers dislike practicing just as much as others do. But more than others, they have the will to keep at it anyway."
---just like that quote.
4) "We find it hard, in medicine, to talk about this with patients." (page 23)
"No matter how accomplished, surgeons trying something new got worse before they got better." (page 30)
---Basically, I just like how he describes the learning process within medicine. Would you accept a "trainee" performing your procedure? Are you brave enough to ask your doctor how many of the procedures he or she has done, and would the answer change your willingness to let them proceed?
So for me personally, I take it as my professional responsibility not to touch a patient unless I know what I'm doing. So if I tell you I'm going to cut you open, you can rest assured I know how to do it right. It is true, though, that I don't have the experience that others may have. And when a rare complication occurs, my first move will be to find someone more experienced. This is also not fundamentally a problem of students/residents vs. certified physicians. I listened this morning to a discussion between a junior and senior faculty member in my department. A patient was scheduled with the younger doctor for a procedure he has not done often. The discussion dealt with whether to tell the patient of the doctor's inexperience or recommend the senior faculty member perform the procedure, among other options.
5) "To the public - and certainly to lawyers and the media - medical error is fundamentally a problem of bad doctors." (page 47)
"And a patient's liklihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care." (page 57)
"We are all, whatever we do, in the hands of flawed human beings. That fact is hard to stare in the face." (page 105)
---My wife is already wondering when I'm going to emerge from this entry, and you probably are too. Let me be brief:
When our oldest was born, my wife was given 10 times the correct dose of a medication. Her heart was overloaded, she went into "flash pulmonary edema," and spent the next day and a half on a ventilator. It was a blatant, clear-cut, medical error. My aunt, a hospital administrator, summed up several people's comments when she said that we should get our hospitalization for free, and could get a whole lot more.
We did nothing. Not because we were not harmed, but because I believed that everyone makes mistakes. The doctor, who was indeed responsible, was legitimately contrite. That was enough for me. In the moment, we were concerned about the long term implications -- not just for my wife but also for our family size due to the emergency C-section that was required. But even with all those emotions, I was more prepared to forgive than to litigate.
But, as the book does point out, people love to sue when the outcome is poor. And (some, not all) lawyers love to help them along.
6) The Man Who Couldn't Stop Eating
OK; we could do a whole discussion on obesity and appetite, but let me just say this much. I agree that some people have a pathologic compulsion to eat. That being said, I am not a fan of gastric bypass surgery. The bottom line is that you make it so painful to eat that the patient retrains themselve. Or rather, some patients. Far too many gastric bypass patients learn to accomodate the change and end up worse than before. In the meantime, you are taking some of the worse possible candidates to the OR and undergoing a surgery with a very real risk of death or disability.
If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves? Gawande gives anecdotal reports of patients who could not possibly have improved without the surgery. I would counter his anecdotes with many others who (in the absence of a successful obesity pill) believe that surgery is easier than fixing their broken lifestyle.
We were not nearly as fat as a country 20 years ago, and again less so 40 years ago. I do not believe that appetite is new to our generation. We have just become too indolent to take care of it ourselves.
-------------
Anyway, I enjoyed this book. Share what you thought; feel free to use my discussion points or not.
The first time I read this book I was pretty early in my medical training. It was fun to read it again after a few years, this time with a much different perspective. I have been there for many of the scenarios that Gawande describes, being as he was a resident. Anyway, I have my own medical opinion of what he has produced. I am interested to know how the rest of you felt about the points he made. Here are some topics of discussion, with my thoughts:
1)"The core predicament of medicine -- the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing -- is uncertainty." (pg 229)
---This seems to be the theme of the entire book. Other than the "mystery" chapters where he details some rare and bizarre conditions, Gawande mostly seems to be explaining just how human modern medicine really is. In spite of all the advances of science, medicine comes down to a fallible doctor in a room with a patient -- and several unknowns.
Personally, I tend to agree. I of course have been working rather diligently (happy birthday, Alvin) for the past several years to learn things most people don't know. I think it's safe to say that I'm better than the rest of you at being a doctor. But in the end, I'm not really perfect at this -- nor will I ever be. I'm basicaly the guy with a competetive advantage for this field.
I remember prior to my mission, I thought there were people who spoke French and people who didn't. It was incredibly naive, but there it is. I remember listening to my MTC instructors use the language so freely, and I did my best to copy them. Even after I got to the country, I thought the more experienced elders were using perfect French. Only with time and experience (and actually a lot of dedicated study) could I recognize that probably 2/3 of the missionaries were finishing their mission with sub-standard French, and markedly American accents.
I think much of America has the naive thinking I used to have about language ability: "A board-certified physician is qualified to be my doctor." In reality, there are widely disparate levels of ability, care, and dedication - to say nothing of the unknowns we encounter no matter our ability. Back when I got into medical school, there were several people who advised me to work hard but not too hard -- "What do they call the guy who gets last place in his medical school class? . . . Doctor." That may be true, but the title only means so much. This goes to the malpractice comment later, but people expect doctors and medicine to behave like a robot and a factory. It's not that easy. "We look for medicine to be an orderly field of knowledge and procedure. But it is not." (page 7)
2) Autonomy, consent, and the role of the patient.
"The decision was Lazaroff's." (pg 210)
"Could it have been a mistake, then, even to have told him about the surgical option?" (pg 216)
"patients frequently don't want the freedom that we've given them." (pg 219)
---I'm curious how you feel about today's world of patient autonomy and informed consent. This idea, that the patient should approve all medical decisions, is strictly taught in our medical schools. It's one of the basic tenets of ethical medical practice -- as much as beneficence and nonmalfeasance. I personally met with about 30 patients yesterday to have them sign "informed consent" paperwork for interventional radiology procedures. The basic principle is that the patient must be of sound mind and aware of the risks, benefits, and alternatives of a procedure before allowing the doctors to proceed.
This all sounds great on paper, or in a courtroom. But personally I don't really like it. I essentially walk into room after room and say (not really here, folks; I'm using hyperbole to make a point...) "Mrs So-and-so, your doctor has asked us to place a stent in your liver. I'm going to ask you to sign a sheet that says we might kill you, but that you want us to proceed anyway. Of course we never try to kill people in our department, but there's always that one you didn't see coming..." That way, when the patient does die, we can point to our document as protection.
But only in extremely rare cases does the patient grasp what may or may not happen on our table today. And almost nobody can objectively detach themselves from the numbers. I can tell patients the odds that we'll cause internal bleeding, infection, and even death. Still, it almost never means they understand the best course of action. In the end, I get two types of people. 1- the patients who look at me with a carefree smile and say "where do I sign?" and 2- the patients who are shocked by all the complications I am forced to mention and sign with "if you really think this is the best thing for me." Interestingly, I have never personally encountered a patient who refused consent for a medical procedure that was recommended by their physician.
OK so there are some patients who are crazy and who refuse consent, but I mean normal people.
So I'm not saying that we should hide facts and decisions from patients. I do believe our current "autonomy" and "informed consent" framework is built around lawsuit protection rather than patient care. I think a more reasonable approach is to discuss the procedure with the patient, in as much detail as they desire, leaving the words "cardiac arrest," "brain injury," "loss of life," and others out of the discussion.
One other (very real today) problem with the "Patient Autonomy" movement is cost. We let patients dictate how much care they do or do not receive.
Wait... pause... My personal code of ethics and even religion are going to come out in this paragraph. Just bear that in mind; I would not and cannot force my feelings on someone else.
Where was I? We are all going to die. All of us. And experienced doctors can tell when you are on your way out. Almost universally, though, we don't recommend stopping care. We sugar coat things and give patients (or families) the sense that there is a better chance of recovery than there really is. So we talk to patients or their families about these expensive and likely futile options, again having the informed consent discussion. We basically leave it up to them if we continue "agressive" care or not. My experience is that almost no one can choose to give up. Either the patient doesn't want to give up(naturally), or the family doesn't want to live with the burden of "not having done everything we could." So the medical costs in the last year of life skyrocket.
Enough about that...
3) "Top performers dislike practicing just as much as others do. But more than others, they have the will to keep at it anyway."
---just like that quote.
4) "We find it hard, in medicine, to talk about this with patients." (page 23)
"No matter how accomplished, surgeons trying something new got worse before they got better." (page 30)
---Basically, I just like how he describes the learning process within medicine. Would you accept a "trainee" performing your procedure? Are you brave enough to ask your doctor how many of the procedures he or she has done, and would the answer change your willingness to let them proceed?
So for me personally, I take it as my professional responsibility not to touch a patient unless I know what I'm doing. So if I tell you I'm going to cut you open, you can rest assured I know how to do it right. It is true, though, that I don't have the experience that others may have. And when a rare complication occurs, my first move will be to find someone more experienced. This is also not fundamentally a problem of students/residents vs. certified physicians. I listened this morning to a discussion between a junior and senior faculty member in my department. A patient was scheduled with the younger doctor for a procedure he has not done often. The discussion dealt with whether to tell the patient of the doctor's inexperience or recommend the senior faculty member perform the procedure, among other options.
5) "To the public - and certainly to lawyers and the media - medical error is fundamentally a problem of bad doctors." (page 47)
"And a patient's liklihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care." (page 57)
"We are all, whatever we do, in the hands of flawed human beings. That fact is hard to stare in the face." (page 105)
---My wife is already wondering when I'm going to emerge from this entry, and you probably are too. Let me be brief:
When our oldest was born, my wife was given 10 times the correct dose of a medication. Her heart was overloaded, she went into "flash pulmonary edema," and spent the next day and a half on a ventilator. It was a blatant, clear-cut, medical error. My aunt, a hospital administrator, summed up several people's comments when she said that we should get our hospitalization for free, and could get a whole lot more.
We did nothing. Not because we were not harmed, but because I believed that everyone makes mistakes. The doctor, who was indeed responsible, was legitimately contrite. That was enough for me. In the moment, we were concerned about the long term implications -- not just for my wife but also for our family size due to the emergency C-section that was required. But even with all those emotions, I was more prepared to forgive than to litigate.
But, as the book does point out, people love to sue when the outcome is poor. And (some, not all) lawyers love to help them along.
6) The Man Who Couldn't Stop Eating
OK; we could do a whole discussion on obesity and appetite, but let me just say this much. I agree that some people have a pathologic compulsion to eat. That being said, I am not a fan of gastric bypass surgery. The bottom line is that you make it so painful to eat that the patient retrains themselve. Or rather, some patients. Far too many gastric bypass patients learn to accomodate the change and end up worse than before. In the meantime, you are taking some of the worse possible candidates to the OR and undergoing a surgery with a very real risk of death or disability.
If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves? Gawande gives anecdotal reports of patients who could not possibly have improved without the surgery. I would counter his anecdotes with many others who (in the absence of a successful obesity pill) believe that surgery is easier than fixing their broken lifestyle.
We were not nearly as fat as a country 20 years ago, and again less so 40 years ago. I do not believe that appetite is new to our generation. We have just become too indolent to take care of it ourselves.
-------------
Anyway, I enjoyed this book. Share what you thought; feel free to use my discussion points or not.
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