There are so many things I appreciate from this Friday Reflection 59. Personally, I never knew how to slow down; this is probably because of my athletic mindset. But what I know now is the urgency of medical training, compounded this intrinsic trait of mine. I only learned the benefit of slowing down after I embarked on a PhD. This skill of dialing back to think about issues that are non-urgent is what every physician needs to learn.
Saw a 67 yo womans chart. Admitted with acute CHF, a foley gets placed for “strict I&O” on the general medicine floor. Foley is left in for three days, has one 38C elevation, no symptoms but urine sent for C&S no UA, by telephone order. Patient discharged home. CHF resolved.
Two days later at 8:00 PM the lab calls ED to report the urine culture growing Whateverbacter spp.ED physician calls patient in and she waits 3 hours in waiting room. Finally bedded, ED physician documents no symptoms or signs.
Patient gets 360 mg of Tobramycin.
“What?”
-Foley not indicated
-Urine culture not indicated
-Return to ED not indicated
-Unnecessary and potentially Ototoxic medication not indicated
The tragedy is, had he gone to the surgeon, he would have had a cholecystectomy, and the ER staff and the surgeon would have believed they'd done the right thing.
I see this repeatedly with non cardiac chest pain. The patient gets a stent for an asymptomatic lesion, and the referring doc and interventionist take a victory lap.
Nice one, Adam. Somewhere along the line, we have forgotten that the most accurate diagnostic "test" is the patient history. The rush to order more tests without first doing what Lown did and what you do bypasses the use of great heuristics like Occam's razor and Bayes' Theorem. Thus, the CT scan has become the stethoscope of the Emergency Department. Unfortunately, the causes of this are so myriad that it is hard to imagine how to turn back the clock
I’m a slave to the “pillars” with a diagnosis of non ischemic dilated cardiomyopathy. It really doesn’t matter how I say I’m feeling on current dosages; I’m being pushed to max dosages because of “better outcomes”.
I am an occupational therapist. We had a patient repeatedly admitted for hyponatremia with “no cause.” After seeing this patient’s history, I asked how much water he was drinking at home. Bottles and bottles to be healthy! MD notified, gave the patient guidelines on appropriate water intake, and we never saw the patient again. Thank goodness I did not follow my first thought that someone else must have asked this basic question..:
This is another great one Adam (may I call you that? After all these years following you I feel that I know you a little). I have to say that, in my experience as a nurse, I saw that nurses are great at getting the full picture. I think it’s mostly because we get to spend more time with people. When the team on rounds listens to what we have to add it can greatly increase the chance for healing. Goi team!
I have to give a shout out to the cardiologist I worked with for many years who trained me in taking a thorough health history. Thank you Alan Radoff!
What a great reminder to slow down and take a decent history. Hospitals are through-put machines with every metric being tracked (door to doc, TAT, TTD, TTA, LOS,etc.) You have two choices, play that game and make the patient somebody else's problem -- as was done here-- or sacrifice the income, ignore the metrics, and focus on the patient. I'd choose the latter any day. It's simply the right thing to do. Thanks Dr. Cifu
We all lament the lack of healing , limited history taking ( frequently by a nurse or MA ) , vanishing physical exam skills and reliance on tests and technology . We do not need to think too hard about why this is the case - time is the common denominator . All these things require time - time spent listening to, thinking and examining . But time is money . With the rise of RVUs the pressure is to see many more patients and offload as many as possible to the CT scanner , the lab and the ultrasound unit - which also brings in revenue for your employer - usually a large hospital system . Spending time with patients is penalized , not rewarded - and the shortage of physicians exacerbates this problem . 6 month waits to get into any IM specialty would turn into 1 yr . I do not have a solution for this , but I do know that we will not solve this with corporate practice of medicine , reimbursement biased towards procedures , reward based RVU pay , and increasing patient skepticism of physician cognitive skills in favor of robots , internet diagnoses , and advanced imaging for every ache and pain .
Protocols are good, but unfortunately, they often take the place of "the art of medicine". Physicals, Good history taking and LISTENING to the patient are invaluable. This loss of "art" has been partially caused by defensive medicine.
Doctoring for profit is now the end game for the medical industry. Healing is accomplished when the body is purged of its demon toxins. That includes drugs and vaccines...all toxic.
Apart from an internal structural difficulty, the nausea, vomiting, and abdominal pain suggest an accumulation of toxins the body wants to get rid of. If this is the case, there will be no long term healing as long as the poisonings continue.
But the medical industry will attempt to claim a virus or some such thing is the culprit. The wheel of hucksterism will grind the patient down with endless tests, drugs and possible procedures all designed to keep the cure hiding in never never land.
True doctoring or healing would leave the patient in a state of wellness never to be seen again. A patient lost would be the most cured. Not gonna happen.
I am old school. As I am now aging and needing medical care from specialists myself, it is depressing to see how taking a decent history and performing a decent physical exam is rarely done anymore. It saddens me.
Like most patients I am hoping for 'best practice treatment''. Interesting case but from it I can't see that 'healing' is any different from that, so can someone explain?
There are so many things I appreciate from this Friday Reflection 59. Personally, I never knew how to slow down; this is probably because of my athletic mindset. But what I know now is the urgency of medical training, compounded this intrinsic trait of mine. I only learned the benefit of slowing down after I embarked on a PhD. This skill of dialing back to think about issues that are non-urgent is what every physician needs to learn.
Saw a 67 yo womans chart. Admitted with acute CHF, a foley gets placed for “strict I&O” on the general medicine floor. Foley is left in for three days, has one 38C elevation, no symptoms but urine sent for C&S no UA, by telephone order. Patient discharged home. CHF resolved.
Two days later at 8:00 PM the lab calls ED to report the urine culture growing Whateverbacter spp.ED physician calls patient in and she waits 3 hours in waiting room. Finally bedded, ED physician documents no symptoms or signs.
Patient gets 360 mg of Tobramycin.
“What?”
-Foley not indicated
-Urine culture not indicated
-Return to ED not indicated
-Unnecessary and potentially Ototoxic medication not indicated
The essay by W. Michael Brode entitled “Number Needed to Treat” in today’s NEJM has ideas that are adjacent to this piece and is well worth reading.
The tragedy is, had he gone to the surgeon, he would have had a cholecystectomy, and the ER staff and the surgeon would have believed they'd done the right thing.
I see this repeatedly with non cardiac chest pain. The patient gets a stent for an asymptomatic lesion, and the referring doc and interventionist take a victory lap.
So true.
Nice one, Adam. Somewhere along the line, we have forgotten that the most accurate diagnostic "test" is the patient history. The rush to order more tests without first doing what Lown did and what you do bypasses the use of great heuristics like Occam's razor and Bayes' Theorem. Thus, the CT scan has become the stethoscope of the Emergency Department. Unfortunately, the causes of this are so myriad that it is hard to imagine how to turn back the clock
I’m a slave to the “pillars” with a diagnosis of non ischemic dilated cardiomyopathy. It really doesn’t matter how I say I’m feeling on current dosages; I’m being pushed to max dosages because of “better outcomes”.
You choose to be a slave. Own it.
Well said
Excellent!
I am an occupational therapist. We had a patient repeatedly admitted for hyponatremia with “no cause.” After seeing this patient’s history, I asked how much water he was drinking at home. Bottles and bottles to be healthy! MD notified, gave the patient guidelines on appropriate water intake, and we never saw the patient again. Thank goodness I did not follow my first thought that someone else must have asked this basic question..:
This is another great one Adam (may I call you that? After all these years following you I feel that I know you a little). I have to say that, in my experience as a nurse, I saw that nurses are great at getting the full picture. I think it’s mostly because we get to spend more time with people. When the team on rounds listens to what we have to add it can greatly increase the chance for healing. Goi team!
I have to give a shout out to the cardiologist I worked with for many years who trained me in taking a thorough health history. Thank you Alan Radoff!
A. Yes definitely Adam. B. I totally about nurses! I always read the nurses’ notes.
There's a pearl worth an entire article.
Already done!
https://sensiblemed.substack.com/p/friday-reflection-14-committing-and?r=n8zko&utm_medium=ios
What a great reminder to slow down and take a decent history. Hospitals are through-put machines with every metric being tracked (door to doc, TAT, TTD, TTA, LOS,etc.) You have two choices, play that game and make the patient somebody else's problem -- as was done here-- or sacrifice the income, ignore the metrics, and focus on the patient. I'd choose the latter any day. It's simply the right thing to do. Thanks Dr. Cifu
We all lament the lack of healing , limited history taking ( frequently by a nurse or MA ) , vanishing physical exam skills and reliance on tests and technology . We do not need to think too hard about why this is the case - time is the common denominator . All these things require time - time spent listening to, thinking and examining . But time is money . With the rise of RVUs the pressure is to see many more patients and offload as many as possible to the CT scanner , the lab and the ultrasound unit - which also brings in revenue for your employer - usually a large hospital system . Spending time with patients is penalized , not rewarded - and the shortage of physicians exacerbates this problem . 6 month waits to get into any IM specialty would turn into 1 yr . I do not have a solution for this , but I do know that we will not solve this with corporate practice of medicine , reimbursement biased towards procedures , reward based RVU pay , and increasing patient skepticism of physician cognitive skills in favor of robots , internet diagnoses , and advanced imaging for every ache and pain .
Protocols are good, but unfortunately, they often take the place of "the art of medicine". Physicals, Good history taking and LISTENING to the patient are invaluable. This loss of "art" has been partially caused by defensive medicine.
Doctoring for profit is now the end game for the medical industry. Healing is accomplished when the body is purged of its demon toxins. That includes drugs and vaccines...all toxic.
Apart from an internal structural difficulty, the nausea, vomiting, and abdominal pain suggest an accumulation of toxins the body wants to get rid of. If this is the case, there will be no long term healing as long as the poisonings continue.
But the medical industry will attempt to claim a virus or some such thing is the culprit. The wheel of hucksterism will grind the patient down with endless tests, drugs and possible procedures all designed to keep the cure hiding in never never land.
True doctoring or healing would leave the patient in a state of wellness never to be seen again. A patient lost would be the most cured. Not gonna happen.
Thanks for this piece on healing, Adam.
I am old school. As I am now aging and needing medical care from specialists myself, it is depressing to see how taking a decent history and performing a decent physical exam is rarely done anymore. It saddens me.
Like most patients I am hoping for 'best practice treatment''. Interesting case but from it I can't see that 'healing' is any different from that, so can someone explain?
Best practice treatment needs to include an appropriate history taking, which seems to have gone my the wayside.