The New York Times has a prominent article about doctors from all specialties opening practices in cosmetic medicine. I think everyone has a right to make a buck being an entrepreneur, but I worry that physicians who indulge in this kind of frivolousness give medical professionalism a big black eye. First, the motivations are obviously pecuniary, or do we really believe that doctors who say, "when you clear up someone’s acne or facial hair, they are as grateful as if you delivered their baby," are doing much more than salving their guilt with self-deception? The statement is so silly it doesn't even really need to be parodied.
Second, the medical profession has many, many legitimate grudges about how its services are valued, especially as physician and hospital reimbursements shrink, even as insurance company executive salaries and pharmaceutical company profits soar, leading physicians to abandon some specialties and geographic areas and to the closure of many hospitals. But is the best, most responsible way, to respond to abandon many of the core principles of medicine in favor of an easy (and superficial) buck? Or will high profile articles like these contribute to a poor opinion of medical professionals?
Ancient oaths, like those of Maimonides, require that physicians heal without regard to their own satisfaction, material or otherwise. Are we really so under pressure that we have to abandon all that?
Friday, December 1, 2006
What do you do when a patient is SICK???
I remember my pediatric rotation in the third-year of medical school. It was lead by Steven Miller (who tragically died in a plane crash recently), and I did the rotation early in my introduction to clinical medicine--right out of classes and into the hospital wards. "The key skill any doctor must have," Dr. Miller said, "is to be able to identify which patients are SICK."
"Of course," you say, "all patients in the hospital are sick. "
But what Dr. Miller meant was, how do you recognize which patients are REALLY sick, that is, maybe-going-to-die-in-the-next-few-hours sick?
Well, it turns out that doctors are often not that good at identifying those SICK patients. Research going back into the 1980s suggests that patients who suffer cardiac arrest in ths hospital or require emergency transfer from the hospital ward to the ICU (intensive care unit) often show signs of getting worse for 6-8 hours prior to the catastrophe becoming obvious. It should be noted that this failure has been documented in the USA, the UK and Australia.
In the specialty of critical care medicine, we pride ourselves on being able to identify and stabilize these extremely sick patients--yanking them from the jaws of organ failure and death by pulling out our ventilators and dialysis machines and special catheters. In the last 2-3 years, there has been a boom of interest in our field to extend the specialty of critical care medicine beyond the ICU and onto the hospital wards, helping to diagnose and treat unstable patients at an early phase. Many hospitals have formed Medical Emergency Teams or Rapid Response Teams to do just this. The Institute for Healthcare Improvement (IHI) even advocates for these teams in its 100,000 lives campaign. The problem, as many noted researchers have pointed out (most recently in the Journal of the American Medical Association) is that there is very little evidence that these teams actually make a difference.
One main flaw may be in the way these teams are activated, or called to see a potentially ill patient. In most cases, the criteria for calling the critical care team for assistance are somewhat vague. To be sure, this may be by design: it is probably better to encourage people to ask for help than it is to put up too many barriers by creating elaborate criteria. Recent research has focused on adding up different variables of a patient's condition to create a score that will help predict which patients are going to get sicker.
The principle of using scores is described nicely in a recent article in the New Yorker by Atul Gawande. In the piece, he tracks the historical progression of the field of obstetrics and gynecology and its progress in lowering infant and maternal mortality rates associated with childbirth, surely one of the biggest triumphs in 20th Century medicine. The moral of the story is that medical care may be better when it provides "by the numbers" care, which flies in the face of the traditional "take care of every person as an individual." Read the piece and decide for yourself.
"Of course," you say, "all patients in the hospital are sick. "
But what Dr. Miller meant was, how do you recognize which patients are REALLY sick, that is, maybe-going-to-die-in-the-next-few-hours sick?
Well, it turns out that doctors are often not that good at identifying those SICK patients. Research going back into the 1980s suggests that patients who suffer cardiac arrest in ths hospital or require emergency transfer from the hospital ward to the ICU (intensive care unit) often show signs of getting worse for 6-8 hours prior to the catastrophe becoming obvious. It should be noted that this failure has been documented in the USA, the UK and Australia.
In the specialty of critical care medicine, we pride ourselves on being able to identify and stabilize these extremely sick patients--yanking them from the jaws of organ failure and death by pulling out our ventilators and dialysis machines and special catheters. In the last 2-3 years, there has been a boom of interest in our field to extend the specialty of critical care medicine beyond the ICU and onto the hospital wards, helping to diagnose and treat unstable patients at an early phase. Many hospitals have formed Medical Emergency Teams or Rapid Response Teams to do just this. The Institute for Healthcare Improvement (IHI) even advocates for these teams in its 100,000 lives campaign. The problem, as many noted researchers have pointed out (most recently in the Journal of the American Medical Association) is that there is very little evidence that these teams actually make a difference.
One main flaw may be in the way these teams are activated, or called to see a potentially ill patient. In most cases, the criteria for calling the critical care team for assistance are somewhat vague. To be sure, this may be by design: it is probably better to encourage people to ask for help than it is to put up too many barriers by creating elaborate criteria. Recent research has focused on adding up different variables of a patient's condition to create a score that will help predict which patients are going to get sicker.
The principle of using scores is described nicely in a recent article in the New Yorker by Atul Gawande. In the piece, he tracks the historical progression of the field of obstetrics and gynecology and its progress in lowering infant and maternal mortality rates associated with childbirth, surely one of the biggest triumphs in 20th Century medicine. The moral of the story is that medical care may be better when it provides "by the numbers" care, which flies in the face of the traditional "take care of every person as an individual." Read the piece and decide for yourself.
Tuesday, November 28, 2006
Screening for lung cancer
There is a good piece in Slate about a recent high-profile article that appeared in the New England Journal of Medicine. The research involves screening for lung cancer, which remains one of the most common and least treatable forms of cancer. The article examines the use of CAT scanning the lungs of "high risk" individuals to find spots that may represent cancer. I think the Slate article does quite a good job explaining some of the pitfalls of screening for any disease and is accessible to many people without medical training. It is sobering to note that very few screening tests have been proven to SAVE LIVES. Even mammography for young women (40-50 years-old) remains controversial. This is a point that causes difficulty for many non-medical people. "If you diagnose it early, it must be easier to treat!" But the truth is much, much messier, and the law of unintended consequences comes into play, especially when the diangosis and treatment of a disease like lung cancer involves pretty invasive and toxic procedures: we just don't know if the complications are worse than the disease.
Welcome to Critical Health
Thanks for stopping by! In the first post, I'd like to answer a few key questions:
Who am I?
I am a medical doctor specializing in pulmonary and critical care medicine. That is, I specialize in lung diseases and the care of patients who are seriously ill, usually in the intensive care unit. I practice medicine at a large, academic referral center in a big city. I spend most of my time doing research, working on the biology of lung inflammation, especially severe respiratory failure.
What is this blog about?
Health care and medicine are among everyone's top concerns. I hope to provide some insight into many issues regarding modern healthcare, especially issues relevant to my specialties. I think critical care medicine, in particular, is a very interesting focus for our debates about health care, because ICU care consumes a lot of resources. Many patients in the ICU lack the ability to make decisions for themselves, highlighting important questions about patient autonomy. Finally, patients in the ICU are often desperately ill, and many will die, raising crucial questions about care at the end of life.
How often will this blog be updated?
I plan to update at least every day, and more if interesting topics arise.
How can readers contribute?
Please feel free to comment on anything you see or draw attention to links you think are relevant. I will review comments and and try to get them posted within a day, hopefully less. The typical caveats about insulting or inflammatory posts will apply, and links or comments that have commercial interests will not be posted.
Who am I?
I am a medical doctor specializing in pulmonary and critical care medicine. That is, I specialize in lung diseases and the care of patients who are seriously ill, usually in the intensive care unit. I practice medicine at a large, academic referral center in a big city. I spend most of my time doing research, working on the biology of lung inflammation, especially severe respiratory failure.
What is this blog about?
Health care and medicine are among everyone's top concerns. I hope to provide some insight into many issues regarding modern healthcare, especially issues relevant to my specialties. I think critical care medicine, in particular, is a very interesting focus for our debates about health care, because ICU care consumes a lot of resources. Many patients in the ICU lack the ability to make decisions for themselves, highlighting important questions about patient autonomy. Finally, patients in the ICU are often desperately ill, and many will die, raising crucial questions about care at the end of life.
How often will this blog be updated?
I plan to update at least every day, and more if interesting topics arise.
How can readers contribute?
Please feel free to comment on anything you see or draw attention to links you think are relevant. I will review comments and and try to get them posted within a day, hopefully less. The typical caveats about insulting or inflammatory posts will apply, and links or comments that have commercial interests will not be posted.
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