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Do we really care about patients ?


SEAL

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Do you think doctors really care about patients ?

By caring I mean going out of one's way to help a patient. Something more than just diagnosis and treatment. 

For example, I was doing a hematology/oncology rotation. And the team was composed of an attending, 4 residents and 1 med student. And we were having an extremely slow day. And then we got this new case where leukemia was suspected and the patient needed a bone marrow biopsy. The standard protocol was to fill out a referral form to the bone marrow clinic and the patient would be seen in 4 weeks.

We were literally sitting all day long doing nothing except some short followups. No one said "hey ... this patient is probably worried about  the possibility of having cancer .... why don't we do a bone marrow right now and save her 4 weeks of sleepless nights "

No. We just filled out a form and that's it.

There are all types of situations where no one volunteers to go the extra mile for the patient's sake. If they don't absolutely have to do it, and if not doing it wouldn't compromise their liscence, they won't do it.

This really begs the question about the point of having MMI interviews where there are scenarios that are supposed to test the applicant's compassion. Is it all just an act ?

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Assuming you were the med student in this scenario, and it already crossed your mind that there was something you could do, could you have taken the initiative and actually did it? I don't mean to sound accusatory, but it's often not just about caring, but acting and taking initiative. It's likely that someone else in the group thought it too, but no one spoke up. Remember that despite the best of intentions, MMIs aren't perfect - you can only know so much about a person in 8 minutes. On top of this, it'll take some time to see the effects of students selected through the MMI, as it's only being widely implemented in the last couple years. It's s bit harsh to say that doctors don't really care about patients or that the MMI's goals of selecting for well-rounded compassionate physicians is just an act. I understand that you're frustrated by what didn't occur, and it's true that patient care can certainly be improved, but selection committees can only do so much, it's also up to us to be the change we want to see and influence those around us. 

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17 hours ago, SEAL said:

The standard protocol was to fill out a referral form to the bone marrow clinic

The way this is written, it sounds like you weren't actually on rotation at a bone marrow clinic - even if your team hypothetically had members with the skill set to do a biopsy, isn't it possible that they didn't have the equipment or had to follow protocol in order for insurance to cover the procedure? I could imagine any number of valid reasons why they had to follow protocol. Can anyone else comment on this?

It could have potentially been a learning experience if you had just asked someone on the team why things were being done in a particular way.

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I did ask one of the residents why can't we do it on the spot. He just told me that the protocol was to fill out a referral form.

I was on a consult team but we attended the bone marrow clinic for a couple of hours each week.

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It's not just this incident  There are lots of other incidents. For example there was this patient with advanced myelofibrosis who was on an expiremental drug. For some reason his renal function was high (I can't remember why now) so the drug had to be stopped. Basically, this patient had lived a remarkable 13 years since diagnosis but now his heart was shutting down and his kidney was shutting down and his blood counts were dropping. The attending just saw him once and I was following him up for 2 weeks and his wife and son had all types of questions that I couldn't answer. One day I told my attending: maybe we should tell him that this is the end. My attending told me flatly: "I am not going to change his goals of care, just follow him up and transfuse as necessary". The next day I told his son to email the myelofibrosis specialist his father was seeing as an outpatient and demand to talk to him to find answers to his question. The next day, that doctor sent a fellow who was working with him who had a meeting with the patient and his family to tell them that he had just 3 months to live and there are no more treatment options and that he should go home and enjoy the rest of his short life.

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Another patient had all kinds of co-morbidities including Afib and was on warfarin. She had leukemia and needed to start chemo. Basically warfarin was the only anticoagulant that could work for her, all other anticoagulants were contraindicated. Problem is, once she stops eating and starts vomiting because of the chemo, her INR would be jumping up and down. No one wanted to make the call on that case. The oncologist (who is originally a hematologist) tossed the decision to the hematologist the patient was following as an outpatient, who tossed it to us, and we tossed it to pharmacy. As far as I remember, the patient's chemo was delayed for 2 weeks because no one wanted to make the decision. My rotation ended before I can figure out what happened.

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Hi SEAL,

How do you feel about what happened? I imagine that because you are talking about this issue here that you are feeling quite frustrated and concerned/angry about the way patient care is handled.   You are not alone, you are having a normal reaction to an imperfect health care system. Have you considered talking about these issues with a school counsellor? 

Are you the only one that  feels that way about patient care? Or do your other colleagues have similar thoughts/ feelings about what's happening?

I don't have the answer to your situation, but I hope someone would join the conversation to help you out.

Did you talk to your attending/resident about your concerns? What was the outcome?

 

18 hours ago, SEAL said:

Do you think doctors really care about patients ?

By caring I mean going out of one's way to help a patient. Something more than just diagnosis and treatment. 

For example, I was doing a hematology/oncology rotation. And the team was composed of an attending, 4 residents and 1 med student. And we were having an extremely slow day. And then we got this new case where leukemia was suspected and the patient needed a bone marrow biopsy. The standard protocol was to fill out a referral form to the bone marrow clinic and the patient would be seen in 4 weeks.

We were literally sitting all day long doing nothing except some short followups. No one said "hey ... this patient is probably worried about  the possibility of having cancer .... why don't we do a bone marrow right now and save her 4 weeks of sleepless nights "

No. We just filled out a form and that's it.

There are all types of situations where no one volunteers to go the extra mile for the patient's sake. If they don't absolutely have to do it, and if not doing it wouldn't compromise their liscence, they won't do it.

This really begs the question about the point of having MMI interviews where there are scenarios that are supposed to test the applicant's compassion. Is it all just an act ?

 

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Hi there, I think it's great you're asking these questions. I hope you hold on to your ideals as you progress through training. Most people I have seen in medicine work very hard on behalf of patients and have dedicated much of their lives to their care - but over time can be worn down working within an imperfect system, and may no longer have the resources to spend time/energy processing/talking about/battling the challenges faced.

The thing is that we do not work in a vacuum. Over PM, I could give you real-life examples of situations where someone took initiative with the best of intentions to help, but ended up making things worse as there were additional factors downstream they were not aware of, and had not taken into account. All parts of the system are interconnected, including many parts we have little influence over directly, but need to rely upon in order to effect the positive outcome we wish. That is why a systems approach to quality improvement is what is needed - more later.

Unfortunately, the resident you asked about the bone marrow clinic likely did not have enough background to be able to answer you adequately. We don't know the history behind the policy, but I could conjure up some purely fictional examples based on what others have suggested:

- Perhaps someone took initiative to do a bone marrow biopsy on their own, but failed to inform the lab beforehand. The lab was not prepared to process the sample, and the sample was lost.

- Perhaps someone without adequate expertise did a bone marrow biopsy, but ended up obtaining a nondiagnostic sample.

In both cases, the patient had to undergo a second painful procedure (they'd much rather endure the wait time instead), and the family was very angry and made a complaint. Therefore, everything was centralized into one process.

I encourage you to channel your frustrations into working to improve the system. Try bringing up your question in a constructive manner to someone who can provide more insight - what are the barriers to being able to provide more timely diagnosis? Are there efficiencies that could be found? Potential for QI project? If there is a chapter of the Institute for Healthcare Improvement at your school or similar group, connect with them. Look into their online courses. I can PM you with more resources if you'd like.

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The other posters have brought up some great points that apply to pretty much all the examples you've brought up, namely that there are systemic and organizational issues in healthcare that underlie a lot of the inadequate care patients get. In these cases, it's often not any one individual's fault. Rather, it's how those individuals work together (or don't work together) that ends up harming patients. As noted, there may be things going on that you're not aware of that contributes to these outcomes which might help explain the actions of those you've worked with, though this shouldn't excuse the ultimate outcome and emphasizes Lactic Folly's excellent suggestion to find ways moving forward to improve system-level problems.

Yet, I think the question you're really asking is "Why don't people give a #$@!?" Even if systemic problems are to blame, the fact that so many physicians seem to treat these problems as tolerable or even acceptable, is extremely disheartening. There are a multitude of reasons why physicians act in ways that seem like they don't care about their patients, here are just a few.

1) Time constraints. Going the extra mile for patients takes time and energy, things most physicians are already short on. Making that extra effort for one patient can take time away from another patient, from a physician's other commitments (including personal ones), or from their quality of life. Physicians may want to do more, but realistically can't. To prevent this, working on time management skills while taking on only as much work as you can handle can help, though it's an uphill battle.

2) Habit. While we like to think of medicine as a job requiring intense problem-solving, much of medicine involves doing the same thing, over and over again. Physicians fall into routines when they encounter a problem, which is generally a good thing, as it means patients get standardized, expert-level care. Yet, when a situation isn't typical, physicians can start to apply their default actions inappropriately. They think they're doing the right thing, even if in retrospect it isn't. Most people in need of a bone marrow biopsy will do well with the referral protocol, even if your particular patient may not. It's hard to break those habits that generally work well for most patients.

There's also good reason to stick to established practices. The best physicians do actively adapt their standard approaches to the particular situation, but that's easier said than done, especially when there's doubt as to what the best approach actually is. Defaulting to an established protocol is at least in keeping with expectations, thereby providing the practitioner with justification for their actions if something were to go wrong, and doing so provides those making system-level changes something to work with. If everyone's following protocol and the outcomes aren't good, the protocol can be changed. If no one's following protocol and outcomes aren't good, that's a much tougher issue to fix.

This is where system-level changes can really help, and working on them can be cathartic for frustrated physicians and physicians-in-training.

3) Training. We talk a lot about being empathetic, compassionate practitioners, but this doesn't get emphasized well in training. As a medical student, supervisors care first about getting you getting a full history and physical, then coming up with an attempt at a plan. That's what gets back to the supervisor for them to do their jobs, and so that's where the majority of the feedback and reinforcement comes from. Moving into residency, doing these things more efficiently and effectively continues to be a focus. Supervisors do want their trainees to care about their patients and act accordingly, but that's hard to evaluate, especially since most trainee-patient interactions are completely unobserved. It just becomes a matter of priorities - trainees have every incentive to improve the aspects of their work they get judged on, so that de-emphasizes the importance of the parts they don't tend to get judged on and these skills atrophy. Addressing this takes vigilance on the part of trainees - exceptional patient care may not be the priority for your supervisors, but it can remain a priority for you.

4) Some people actually don't care. I believe this is a small subset of physicians, but they exist. Avoid them like the plague if at all possible.

You're certainly not alone in your thoughts on this. I've definitely had stretches where I wondered whether anyone around me cared about the patients we were supposed to be helping. What I've found useful is to look not just at the (many) examples of patients who don't get the best care, or physicians acting in seemingly harmful ways, but at the counter-examples, the time when physicians do work in their patient's best interests. These are harder to identify at times, and always less shocking, but they happen regularly. Most physicians care about their patients and are trying their best for them, but they're not perfect and working within a very imperfect system.

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Honestly those are good examples.

It sounds cliché but--not all doctors are like this.  Some will go above and beyond system requirements to help patients.  The best thing assuming you are already in medicine is to try and be the doctor that doesn't get bogged down in systemic bs and tries to do good.  Try and remember these feelings once youre done.

 

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  • 2 weeks later...
On 6/12/2017 at 8:08 PM, SEAL said:

Another patient had all kinds of co-morbidities including Afib and was on warfarin. She had leukemia and needed to start chemo. Basically warfarin was the only anticoagulant that could work for her, all other anticoagulants were contraindicated. Problem is, once she stops eating and starts vomiting because of the chemo, her INR would be jumping up and down. No one wanted to make the call on that case. The oncologist (who is originally a hematologist) tossed the decision to the hematologist the patient was following as an outpatient, who tossed it to us, and we tossed it to pharmacy. As far as I remember, the patient's chemo was delayed for 2 weeks because no one wanted to make the decision. My rotation ended before I can figure out what happened.

Damn this shouldn't have happened. I do feel sometimes we need to make calls instead of just passing the buck. There is a risk versus a benefit in this situation and at the very least we shouldn't toss this to pharmacy. It could make sense if you wanted the other specialist's opinion first, but a pharmacist isn't going to know enough about the patient's situation to make that call. 

I think in this situation, we should explain the pros and cons to the patient, let the patient have make the decision, if they understandable feel overwhelmed, don't understand and want us to make a decision, we make a decision based on what we think is best. 

 

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