The Lost Art of Medical Decision Making

Ms. Smith (name changed) is 82 years old, but currently looks about a hundred.  I met her, intubated, in the ICU two weeks ago.  She lived alone, hadn't told family she wasn't feeling well, but had called 911.  In the emergency department, she was struggling to breath, and was intubated, having gone into respiratory failure.  She was found to have a severe pneumonia affecting the majority of both her lungs.  She also went into heart failure, causing her to retain fluids in her lungs.  Then she went into kidney failure, making it much harder to use diuretic medications to get rid of that fluid, which would help the lungs heal from her pneumonia.  Then, she was found to have - or be having, more precisely - a rather sizable heart attack that ultimately damaged her heart's ability to pump.   That's when I got called.  

The question I was asked was:  did the heart attack come first, just before she called 911, causing her to go into heart failure, retain fluid, and then develop a subsequent pneumonia and kidney failure; or did the pneumonia come first, putting such a strain on her heart and kidneys that she suffered heart failure, a heart attack, and kidney failure?  It's the classic chicken-and-the-egg story in the medical setting.  Most people this age, who are this sick, have multiple things happening virtually at once.  We end up treating them all hoping something will help make them better. 

But in this case the question wasn't entirely academic.  If the heart attack came first, then we could potentially go do something - intervene - on the process by going to the cardiac cath lab, giving her lots and lots of really high-powered blood thinners, and attempting to put in a cardiac stent into her clogged coronary arteries.  If the infection, the pneumonia came first, then giving her lots and lots of high-powered blood thinners could be extremely dangerous, making a bad situation potentially even worse by causing diffuse bleeding associated with a dysfunction of her blood system, a condition called DIC, which can happen when people have multi-organ failure from an infection.  Not to mention that she was so sick, and old, and frail, that the very act of moving her to the cath lab from the ICU and performing the procedure carried sufficient risk as to potentially cause as much or more harm than not doing the procedure at all. 

So, "tag", I was it.  It was my job to decide which of these two approaches to treating - or managing to use a better term - her heart failure and heart attack was the best option.   Knowing of course that if I was wrong, I could harm her, and that she was sick enough that any little extra bit of harm could prove fatal. 

When you go see your doctor, you are paying for a service.  Not many people understand what that service is.  We often think of the service as the act of doing:  prescribing the medication, ordering the test, doing the procedure or surgery.   But the real service isn't the act of doing: the act of doing in medicine can and often is relegated to individuals with less training and experience than your physician.  The prescription can be filled out and the test often run by a technician; the procedure often times almost completely done by an assistant. 

The true service your doctor is providing is thinking.  Should I order the test?  Is there enough data, or do I have enough experience, to think that doing this procedure or using this medicine will help, or at least not harm?  In procedural-based specialities like cardiology, one of the truisms we teach young doctors-in-training (also called residents and fellows) is that just because you can do something or order a test, doesn't always mean you should.  

This is the art of medical decision making, and this is the part of being a physician which can't be delegated to a computer algorithm, or nurse assistant, or robot.   As much as your insurance company, or some credentialing organization, or medicare guidelines want to try, the thinking part of medicine - what goes on between your doctor's ears when you are together with him or her in the exam room - is the most vital aspect of modern medicine and the most important skill your physician can hone.  It makes the difference between good docs and bad ones.  It is hard to measure, and almost impossible to quantify using claims or medical records data, because it does not fit nicely into a check box to be scanned by the millions into computer databases for future analysis.    

Physician's know that this skill is what sets apart the really good clinicians, the people we refer our family members to, and the one's we seek out for our own care.  This skill is also what is sorely lacking in modern training programs, where the residents and fellows have such stringent work-hour limitations that they have only limited opportunities to face these types of situations and to get the experience to guide their future decisions.  

So, Ms. Smith and I sat with each other.  I talked to her family, reviewed her tests, read her chart, did a physical exam, analyzed the findings.  And I made a decision.  No one else made that decision.  It was my call, my responsibility, my job.  There was no protocol or guideline to follow, no data in a peer-reviewed journal, no randomized, double-blind placebo-controlled trial of 82-year-olds with multi-organ failure critically ill having a heart attack and wondering which came first, the chicken or the egg, and what to do about it.  There was no manual.   I made a medical decision based on my experience and training in doing so.  

Today, nearly two weeks after she arrived at our hospital,  Ms. Smith and I had a nice conversation.  She is off life-support, breathing and eating on her own, lungs healing, kidney's responding, and heart pumping better than it was when I first saw her.  It was her second day off the breathing machine, and her first day awake and alert enough to talk with me.   She was transferring out of the ICU to the step-down unit, and the physical therapists had been by to start working with her to regain her strength and independence.  She was very pleasant, and her family sat nearby and beamed, knowing how sick she had been, and how close she was to not surviving the last two weeks.  

At the end of our brief conversation, we shook hands, and she said she was glad to meet me.  

I smiled and told her I was glad to finally meet her, too.  

When can we put medicine back into the national healthcare debate?

I was on-call this past weekend, rounding at about 8 am on the cardiology floors, and a woman I didn't recognize approached me.  She asked if I remembered who she was, and was quick to tell me that if I didn't it was ok.   She had had bariatric surgery about 6 months previously, and I had seen her in the office for a pre-surgical consultation.  

She went on to tell me that she had lost 80 pounds since her surgery. She no longer had diabetes, and was no longer on high-blood pressure medication.  Her cholesterol levels had fallen in half, and she was now exercising every day.

And then she did something unexpected:  she thanked me for talking to her when she had her office visit with me six months earlier.  It turns out she was initially very hesitant to have the procedure done.  She didn't want to go through all the "hoops" that her doctors, and insurance company, required prior to having the surgery (by the way, a visit with a cardiologist to ensure that her heart was healthy enough to have the surgery was one of the hoops).  But we sat and visited, and although I don't remember the conversation at all, she told me that my taking five minutes to talk with her -- instead of clicking boxes on the computer, or instead of rushing her out the door -- made all the difference, and guided her towards what she needed to do to take care of her health.

There are a multiple different lessons from this anecdote.   Amongst the most important is the knowledge that what we as physicians say and do, and how we say it and do it, matters.  It's not just the medical knowledge, although sharing with her the benefits to her health over the long term of controlling her weight, diabetes, hypertension and hyperlipidemia did influence her decision.   But it's the manner in which information is conveyed, and the place, and the timing.  It's little things like turning away from the computer and looking someone in the eye when talking with them.  It's treating people with respect, courtesy, and as equals, not as yet another number to move through the office.

I think about how are our "healthcare system" is trying to rearrange itself, and wonder what will happen to encounters like this.  Most physicians enter the field of medicine because it gives us a chance to give back to others what we all have most likely been given at some point along the way.   And although the current "check-list" paradigm of making sure that the basic things are done right (e.g. treating blood pressure and diabetes to appropriate targets to minimize risk of future adverse events) helps us as physicians focus our efforts onto prevention and disease management, our method of doing so matters.  Would a web-based form or a self-assessment tool or a phone call to a nameless person hundreds of miles away had the same effect for this patient as our face-to-face encounter did?   If I had simply clicked my through the required boxes on my EMR template (which are required not by me, but by Medicare, so that I could get paid for the time I spent with her), would the outcome have been the same?  She was reassured precisely because I wasn't a provider or communicator or technician or a computer entry specialist, but rather a doctor, a physician, and because I took five minutes to act like one.

Ultimately medicine is about people and about relationships.  You can't legislate relationships.   You can't put a price on it.  You can't figure out how to reimburse it or how much each minute of that relationship is worth.  It's hard to imagine that if we - the house of medicine - could do a better job on our end, and that if they - the payors and regulators and legislators - would let us and require less administrative work, that the end result wouldn't be the type of healthcare system that we all are hoping to achieve.

The Failures of Current Graduate Medical Education

When a doctor finishes medical school, he or she then faces what is truly the most difficult part of their journey into becoming a physician:  graduate medical education.  The goal of internship, residency, and fellowship training programs -- what is collectively called Graduate Medical Education, or GME -- is to take newly minted doctors, just out of medical school, and turn them into competent physicians, able to practice in their specialty independently.   And if you're asking, yes, there's a difference. 

When a doctor finishes medical school, he or she has been exposed to a lot of data, and has learned a few basic facts about how to be a physician.  But the haven't learned really how to work independently in a field of medicine.  That takes the 3-10 extra years of training collectively known as GME to acquire that skill.  It is a skill that encompasses a lot of "non-data" abilities, one of the most critical of which is the ability to make a decision independently without having to ask someone if it's the right decision. 

GME is hard.  It is filled with long hours, late nights, and a whole lot of imposed stress.   The faculty in these teaching programs are charged with taking young doctors and teaching them the art and science of actually taking care of patients.  That occurs through years of supervised practice, with gradually increasing responsibility.  Ideally, the last year of one's GME should be spent working as a de facto attending, being supervised only nominally.  In this way, the programs can assure that the graduates are able to hop from their training program into practice in a seamless transition. 

It doesn't happen that way so much anymore.  More and more the candidates we interview for our practice that are coming out of training are woefully unprepared.  While they may have passed lots of tests, and acquired lots of book knowledge, they lack these non-data skills to be a good physician.

The glaring omission in these new GME graduations is the lack of ability to work independently.  When I was a first-year cardiology fellow, it was my job to run the CCU at night.  If I had to call the attending for help, it was a failure.  And the attendings let me know it.  If I couldn't make the right call - does the patient need urgent heart surgery or can it wait till morning?  Does the patient have septic or cardiogenic shock?  What test do you need now to stabilize the patient, and what can wait till morning?  -- that was a failure.  And for the next week that failure was hammered into you.  Papers were read, management techniques discussed, decisions picked apart, in a painful and sometimes embarrassing recounting of your failures.  During work rounds, during conferences, during lunch, it was dissected, pulled apart, analyzed, discussed, and corrected. 

But that doesn't typically happen anymore.  Training programs now are less harsh, less demanding, and for lots of reasons - work hour restrictions, work load restrictions, and just plain old lack of grit - the products of those programs are less prepared for the stress and strain of being an independent physician.  The difficulty in this process, in going from doctor to physician, is when you finally realize that there is no one else behind you, and you have to make the decision, and in your hands, and with that decision, rests a person's health, well-being, and sometimes life.   Without that training that strives to ensure that whatever else happens, you are ready to act as a independent physician upon graduation, many newly minted post-GME doctors just aren't ready to assume the mantel of being a physician.  They aren't able - because they never have had to make any independent decisions before.

I think this thrust of training programs is a huge disservice.  As we have looked for additional partners for my practice over the years, a common theme has emerged.  The doctors coming out of current GME training programs do not know how to act as a independent physician.   They are unable to decide the right test to order, or the right medicine to prescribe, or what to do in the middle of the night when they are called to the bedside of a patient whose blood pressure is dangerously low, or who can't breathe. 

GME programs are ideally designed to take newly minted doctors and turn them into professional physicians, able to walk out of their training and start running a practice.  They currently are not succeeding.  One of he areas that this is manifest is the inability of new GME graduates to bear the responsibility of making a decision that may, in that moment, affect someone's life.    The training required to attain that level of confidence and knowledge is tough.  Our relaxing of the standards we hold GME trainees to is starting to have the adverse consequences of producing less-than physicians.  And this is a big disservice to our patients, current and future. 

Three Health Care Systems

I was reading a blog about health policy and the failings of the ACA rollout posted on CNN (the link is: http://www.cnn.com/2013/11/14/opinion/carroll-obamacare-reality/index.html?hpt=hp_t4).    The author spends time talking about how much we, the people who live, work, and need healthcare in America, want to change our healthcare system.  And how, since change is hard, no one should be surprised by the pains accompanying this change, particularly in terms of individuals loosing their current insurance policies due to the rollout of the ACA regulations on what health insurance policies must now cover.  

As I have thought about this, I think the issues need to be reframed.  While everyone in general seems in favor of healthcare "reform", there has been little thought given to what that means or should look like.  It is my opinion, based on discussions with patients and colleagues alike, that we really don’t want to do away with our current health care system; we want to modify it to fit current needs. 

What we really need are three simultaneous health care delivery systems. We already have the best system in the world at treating acute illness. If you have a heart attack, or are in a car wreck, or get appendicitis, there is no better place in the world than the US. But if you have diabetes, or hypertension, or had your heart attack 15 years ago, what you need is a disease management system, which is very, very different than acute care. We don’t do that well; in part, that is because disease management is actually a very young science which is not taught particularly well to physician trainees. I am a cardiologist, and spent nearly all my training in the hospital dealing with acute illness. But in my clinical practice, I spend a majority of my time in my office dealing with chronic disease management: my patients with heart failure, or high blood pressure, or known coronary disease, or who had their heart attacks weeks, months, or years ago. How often should they be seen? What is the best therapy to prevent acute exacerbations or recurrences of their disease? Is one class of medication better than another at keeping them “stable” and out of the hospital? Do routine tests help, hurt, or make no difference at all? Our system is starting to grapple with these issues, but only just starting.

We are great at acute care. We are trying to rapidly learn best practices in disease management to care for those with chronic disease who drive most of these healthcare costs. And the third pillar that we need, which we do exceedingly poorly, is disease prevention. What tools do we have, and what do we need, and what works, and what doesn’t? This has not even begun to be discussed in the medical literature, and should be.

One of the complicating factors in health care, however (versus other production oriented endeavors like systems engineering, for instance) is that individuals move rapidly between these three aspects of a healthcare system with sometimes rapid, sometimes upredictable, and sometimes urgent necessity. Many people who haven’t paid any attention to disease prevention, for instance, suddenly find themselves needing acute care – say by having a  heart attack. Then afterwards they now need chronic disease management for their coronary artery disease.  Perhaps they now have a form of heart failure too, and need disease management for that. And of course these chronic disease states will have acute exacerbations at some frequency. But that same patient may also now live long enough to develop cancer, or a neurological disease, or have a car wreck. So while they passed beyond disease prevention for cardiac care and now are in a cardiac disease management bucket, they may still be in a disease prevention bucket in another area – such as cancer prevention.  People may often be in multiple buckets at once:  disease management for their hypertension and high cholesterol, disease prevention for the risks of heart and vascular disease, and acute care for a herniated disc, or acute appendicitis, or the flu.   It is very hard to engineer a healthcare solution that recognizes that an organization as complex as a human being can be in several of these buckets at once, and that each requires a somewhat different approach in terms of optimizing care.  

We desperately need our “system” to get a better grasp on how to prevent acute and chronic disease, and how to manage chronic disease better, more cheaply, and with better outcomes. But we don’t want to let go of our system's ability to deal with episodes of acute illness – everything from broken bones to heart attacks, appendicits, and the like – while this transformation occurs. That is the real danger with these social engineering attempts at transforming, reforming, or trying to reshape the healthcare system.