Complexity in Hospital Medicine

I attended a talk today by patient safety guru Dr. Wachter (whose book I reviewed previously) and it really got me thinking. The problem with modern day medicine is that it is awfully complicated. In the past, doctors only needed to know 40 or so drugs very well: heparin, morphine, digoxin, beta-blockers, and a few antibiotics. Today, the capable intern needs to know about 10 times more medications. Each area of the hospital - wards, emergency department, operating rooms, intensive care units, even psychiatric units - has become more specialized; equipment has become more esoteric; patients have become more "complex" meaning those with diseases which may have been fatal in the past are now surviving.

In the past, the well-trained, hard-working, well-meaning physician could be successful; by sheer diligence and integrity, he could take good care of his patients. Dr. Wachter argues that this is no longer the case; we must still have well-trained, hard-working, well-meaning doctors of course, but this is no longer sufficient. The complexities of medicine make it so that even a perfect doctor will make mistakes. This is a hard fact to swallow; we don't want to think that a person who does everything by the textbook will mess up, but he argues that human error is inevitable. Despite the years of school and postgraduate training to make a doctor, medicine has become so hard that we cannot always do everything perfectly. To err is human. As a result, we must set up systems and barriers that prevent inevitable human error from affecting patients. Whether it is computer prompts about medication interactions, nurses reading-back orders to confirm them, a culture where medical students can challenge an attending, or checklists to make sure anesthesiologists don't forget antibiotics, something more than "training good doctors" must be in place. Great doctors are necessary, but not sufficient for great care.

Poem: Parting

Sorry, I have been remiss in blogging the last few days; it has been unusually and temperamentally busy. I'm hoping to get back to a regular and more manageable schedule. In any case, here's a poem I jotted down this weekend.
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Parting

How do friends part this good place?
In his linger-laden fingertips
cataract-shrouded eyes
I recognized mind's release

flowering memories, nameless
curtains, a careless return to
smog-scoured youth.
Reason fled, took sanctuary

in my mind, and what solace
I could muster banked hard left
escaping into the warm breeze.
Sentimental, I scorned. It should

be cold, and there should be snow,
but he, who had only seen snow
on television and in dreams,
squeezed once, let go.

Hospital Construction

I'm going to delve into a topic I know very little about. I've visited over 20 hospitals in the last few months for interviews and I've noted an interesting trend: hospitals seem to be indefinitely under construction. Whether it is seismic earthquake safety retrofitting or revamping old operating rooms or adding a new ICU tower or constructing an outpatient facility, hospitals always seem to be upgrading. On some of the hospital tours I went on, buildings have been haphazardly constructed and connected such that a fifth floor in one building connects to a third floor in another which, after ascending half a flight of stairs, leads to the seventh floor of a garage.

I sometimes wonder: is it better to simply upgrade hospitals, as if tacking on or repairing things as needs arise, or is it better to tear an old hospital down and build a completely new one? Obviously, tearing down an old hospital has a lot of problems. Many hospitals simply cannot close; patients are constantly being admitted and discharged, and some patients have been there for months or years. Communities have grown accustomed to and dependent on hospitals, and it's simply not okay to temporarily close a hospital in order to build a new one. Furthermore, the cost of building a completely new hospital is extravagant while constructing one tower at a time is economically feasible. Some hospitals combine the two by building a new facility in piecemeal, allowing patients to be shifted around and controlling costs.

However, I sometimes wonder whether in the long term, it is better to build completely new facilities. Newer hospitals can save money in the long run if they are built with energy efficient principles, designed to manage waste effectively, and constructed in an environmentally friendly manner. They can deliver better care with individual patient rooms, larger ICUs and ORs, better lighting, and more family friendly areas. Indeed, simple patient rooms can be more homey and welcoming rather than sterile and isolating. New hospitals can definitely have better elevator design, more efficient transportation of patients, and better wireless internet access. Perhaps even more innovative technologies can be used such as solar panels for energy production or better isolation systems (especially with diseases like H1N1). Even basic things like the ward structure can be examined - are they really necessary?

The Principle of Double Effect

The principle of double effect is a philosophical idea often invoked in discussions about palliative care. First proposed by St. Thomas Aquinas, it asks about the morality of an action that has both good and evil effects. For example, in a terminally ill patient, administering pain medications may end up shortening the patient's life, but if it is done with the intent of alleviating suffering rather than shortening life, then is it permissible? Thomas Aquinas argued that an action with both a good effect and a harmful one is justifiable if the nature of the act is morally good (or at least neutral), the agent intends the good effect, and the good effect sufficiently outweighs the negative effect.

At first, these criteria seem overly onerous but they adopt many key ethical ideas. For example, intent is central to an ethical framework endorsing the principle of double effect. Euthanasia is not permissible because a lethal dose of drug is given with the intent of killing a patient. But palliative sedation may be allowed because a dose of drug is given to alleviate a patient's pain and suffering even if there is a foreseeable consequence of the patient dying. In the same way, it is not permissible to bomb a civilian city in a legitimate war. But the principle of double effect may exonerate bombing a military target even if the agent knows that there are civilians there who will be killed. The intent of each scenario is different even if the consequences involve something negative.

Some people may find this argument distasteful. True utilitarians (or consequentialists) believe that an action's moral nature depends only on the net good or evil generated by the act. And others may find the distinction between intent and foresight blurred. If an action has a foreseeable inevitable harm, then can you intend the action without intending that inevitable harm?

In medicine, we do things that take the principle of double effect for granted. In many cases, the harmful effects are labeled side effects or complications. For example, we give patients medicines with the intent of helping the patient despite a foreseeable possibility of headache, nausea, vomiting, or even worse side effects. We justify this harm in a risk-benefit analysis. In taking out someone's infected appendix, we justify this action because it saves the patient's life despite an inevitable foreseeable consequence of pain. Appendectomies are intended to save lives not inflict pain. Those examples are not really that controversial. But what about this: let's say a pregnant patient has uterine cancer. Her physician thinks abortion is unethical and refuses to do abortions. However, the physician justifies taking out this patient's uterus - and thus, terminating the pregnancy - because of the principle of double effect, that she intends to save the patient even though she foresees the loss of the fetus, and that the risk-benefit analysis favors this action.

Note, the principle of double effect is not simply about risk-benefit analysis. Imagine in the last example that the patient was a 16 year old (I'm not sure why she might have uterine cancer, but we'll ignore that) and imagine the physician felt strongly that 16 year olds should not have children. Perhaps she does the hysterectomy with the intent of both curing the mother and aborting the fetus. Because she now intends this harmful consequence, she cannot justify her action by the principle of double effect.

The Problem with Evidence Based Health Care

Evidence Based Medicine is the idea that our medical decision-making should be governed by data from well-designed research trials, and indeed, clinical research defines the basis for much of what we do and the standards of care we deliver. Well-designed research gives us a strong inductive justification for diagnosis, testing, prevention, and treatment and is generally considered stronger than theory or expert opinion. Many practitioners may believe that only high quality clinical research should guide health care, and perhaps in an ideal world that may be true. But in actuality, evidence based health care runs into conflict with many other modalities of health care decision making. One of these became very real recently and that is politically defined health care. Though many find the influence of politics on medical decision making distasteful, the reality is that it is here to stay. From the political fallout of recommending less breast cancer screening to a failure of a movement to push for universal health care, we find that the delivery of health care is influenced by politics, media, and public perception. In a similar vein, health care economics greatly influence medical decision making. In fact, a substantial amount of clinical research goes into determining whether something is cost effective or not. Tests, treatments, or interventions may be beneficial for a patient but if they are too expensive, they won't happen. Even though we insulate doctors as much as possible from these less noble influences, ultimately, health care is guided by a myriad of factors, only one of which is what scientifically is best for a patient.

May Not Be Suitable for Everyone

Not all viewers may want to see the following picture of an eye surgery so I've sized it smaller than usual (click to enlarge). I debated with myself whether to post this or not since I was mildly taken aback by it and some people might find it a little disgusting. In fact, I decided against ophthalmology simply because I would not be able to do something like this. But this example of strabismus surgery is a gorgeous photograph showing the medial rectus being disinserted following pre-placement of Vicryl sutures. A forceps is grasping the superior pole of the muscle, a speculum is holding the eye open, and scissors are cutting. From an anesthesia standpoint, eye surgeries are on the more boring side of things, but the precision of such a procedure is quite amazing. This image was a Wikipedia picture of the year in 2006.

Image is in the public domain, from Wikipedia.

Poem: 1960s

I have to admit, I struggled a while with this poem. Writers sometimes talk about not forcing a story or poem to go somewhere it doesn't want to go, and this poem really lead its own way (appropriate, given the subject matter). I'm still having trouble with the rhythm and ending but I'll have to sleep on it; that's what revision is for.
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1960s

Like all women of my generation
I never had a say, never had a voice
but now revived, I look about and cry--
take arms, take pitchfork, burst
from tower and castle and countryside
and hear us--
we will not be defined by birthmark
or congenital curse, will not be defined
by a home of chimney dust or orphanage.
This is not our fate, to wander forest roads
or grow hair in vain or await
handsome cobblers a-knocking.
No--this new century it is time
for those spindle-enchanted women
to cast off that cloak of anesthesia
and slap that costumed buffoon
because we pick our own apples
we defy mirror-talk
we scorn dwarf and prince alike.

Kidneys

For my next rotation, I am teaching in the first year medical student course on the kidneys. I really enjoyed teaching in the cardiovascular block, and so I asked to teach in this block as well. It's really fun, it's very fulfilling, and the first year medical students are awesome. Luckily, I even have some of the same small groups as before. It's also very useful for me to review the kidney, electrolytes, and acid-base problems. I'll be facilitating 12-student sections in physiology, pharmacology, and clinical medicine. I'll have preparation sessions for each small group, but otherwise my time is fairly flexible, and I'm really enjoying that.

Image is in the public domain, from Wikipedia.

The Match

The Match is an odd system of determining residency employment, and I'm not sure if there are any equivalent employment processes for any other fields. After a standard application and interview process, no letters of acceptance or rejection are sent. Instead, each applicant makes a "rank order list" of all the programs she likes in the order of preference. Each program makes a list of all the applicants they like in the order of preference. These lists are processed by a central computer algorithm that then generates a "match list" of the optimal pairings between applicant preferences and program preferences.

It's an interesting system that was historically borne from unequal and unfair residency job offers. In the past, there was little standardization of how to go about obtaining a residency position or how programs were to recruit residents. This led to confusion and apprehension by residency applicants which ultimately may have contributed to applicants accepting suboptimal residency offers. For example, if a mediocre residency offered a position, it might be better just to take that definite job than wait for the better residencies to reply. Now with the Match system, the timeline is standardized and applicants and programs make their decisions with more information.

That being said, I don't know if it's an optimal process. For applicants, it feels as though we've lost an element of control. In the past, rolling admissions have allowed us to accumulate acceptances and/or rejections, giving us a sense of how we were doing and allowing us to "hold on" to an acceptance while we see if we get accepted to higher-desired programs. Here, applicants don't have any certainties and go into the match with a risk of not matching anywhere (leading to a more frantic process called the scramble). This uncertainty in a population of medical students who like assurance can lead to unnecessary costs. We end up applying to more programs than necessary to assure that we will match somewhere. Whereas when applying to medical school, I may cancel a "safety" school once I got in somewhere else, in the Match process, I don't have any acceptances and must keep those safety programs in the case that I don't match at the "harder" institutions.

Furthermore, this process may hamstring job negotiation power. In the past, lawsuits have brought up this issue (but have not been successful). Without knowing if I've gotten into any programs, I have no negotiating power or leverage prior to securing the job. Since I must sign the contract for the program that I match into, I have no negotiating power after the match. This may not be all that important, but it's something absent that is common in other fields.

Overall, we want a method of determining residency positions in a fair, equitable way for both applicants and programs. We want applicants to strive for optimal programs, and we want programs to fill their slots with optimal candidates. A Match process may facilitate that, but whether its optimal, I'm not convinced. Nevertheless, it is here to stay.

Medical Workforce

In the 2009 Residency Match, there are 25,185 positions offered. There are 36,972 applicants registered, and of those, 16,008 are U.S. allopathic medical school seniors and 20,964 are independent applicants (former graduates, osteopathic applicants, and international medical students). How do we interpret these numbers? On the one hand, we have enough positions for all U.S. medical school graduates, and indeed, we have room for more. With the greater need for physicians, some medical schools are expanding their class sizes, and hopefully there will be residency positions for all these graduates.

On the other hand, we don't have enough positions for all the applicants. If we expanded residency training, the applicant supply would meet those slots, mostly with international medical graduates (IMGs). Indeed, these graduates often go into the fields that need more doctors such as primary care. But whether or not we should be training so many IMGs might be controversial; this often puts a brain drain on the countries supplying those residents. That is, other countries are training medical students that ultimately leave to the U.S. and may not return to their home country. This is a detriment to those countries, and we should not try to exacerbate that problem.

The reality of this situation is that residency positions are unlikely to expand. The funding for resident training comes from Medicare, and in an era with overwhelming healthcare costs and an uncontrollable federal debt, we are unlikely to fund more training spots. But that leaves us with this question: without training many more residents, should we be expanding medical school classes? And what should our attitude be towards independent applicants and international graduates?