"LAW & ORDER: SPECIAL ETHICS UNIT"

An editorial in the NEJM this week concerns medical futility in Texas. Dr. Robert Truog MD writes about the case of Emilio Gonzalez.

Emilio had been diagnosed with Leigh’s disease, a pediatric illness which is fatal. Sometime before he was 2, he ended up on life support at Children’s Hospital of Austin for five months! Dr. Truog describes some of the painful events, especially how the mother refused to let the hospital move the child. She took the hospital to court, but before the judge could issue a ruling, the child died.

(Does this outcome vindicate the judgment of the doctors? Hmmmm….)

Anyway, it’s a sad ending to a sad case. But this is not what made me angry.

It’s Dr. Truog’s take on ethics committees themselves. Here’s what he says:

“ ...most members are physicians, nurses, and other clinicians from the hospital staff... they are unavoidably “insiders,” completely acculturated to the clinical world and its attendant values. This is hardly a “jury of peers” for a low-income woman of color and her infant son.”

He feels that the ethics committees agree too often with providers. (He states later that ethics committee at Baylor agreed with the clinicians 43 out of 47 times. Gee, I wonder why.)

I will tell you why: Because they know what they are doing.

First, I hate the seamy implication that because the woman is of “color” and is “low income”, that the doctors involved (pediatricians, I suppose) were more willing to treat them unfairly. They kept him on life support for FIVE MONTHS!!! And he died of his TERMINAL ILLNESS!!! (It’s like Terri Schiavo all over again).

Additionally, I do not understand AT ALL his beef that the committee is made up of mostly doctors, nurses and people who are “insiders”. WHO SHOULD IT BE??? Lawyers and people who have never cared for a sick person a day in their life!!???

I’m sure we’d all like someone with no clinical judgment or experience except what they’ve seen on TV to offer an ethical opinion. That makes as much sense as letting a postal worker manage your finances!

Ethics committees are correctly loaded with people who understand a life is at stake, and that family members are the best advocates of the patient. The fact that they agree with practitioners is a testament to the practitioners’ clinical judgment, NOT evidence of a “conspiracy”. I mean, did anyone ever meet someone on an ethics committee who wasn't a "touchy feely" do-gooder? I sure haven't.

Also, what is with his obsession with the whole “jury of peers” and “due process” systema? This isn’t a court of law. It’s an ethics committee. There is no need for a “jury of peers”. No one is on trial. Doctors, nurses, social workers and clinical minds are trying to come to a solution, much the same way a “tumor board” works. I don’t think anyone would call for a “jury of peers” at Tumor Board, if a patient’s cancer treatment was to be decided. That’s because it isn’t appropriate.

Dr. Truog has got it wrong.

SPECIALISTS: THE DELICATE GENIUS

A recent thread of posts about the relationship between PCP’s and specialists, spawned by Dr. Rob’s sardonic “open letter” has inspired me to comment on one particular beef I have with consults.

Specifically, in-hospital consults.

I won’t comment on the anger that bubbles inside me when a consult fellow will just outright “refuse” to see someone because they don’t think it’s an “appropriate” consult. That’s a whole different blog entry.

No, I want to comment on the annoying tendency of specialists to say absolutely NOTHING!

Here’s an example. An older patient comes with some bright red blood per rectum. They may have a history in the family of colon cancer, or maybe they were anemic. Whatever. The consult note usually reads thusly. First they mention the chief complaint, then they have a brief history, then there is the ubiquitous rectal exam.

And then at the end it says “Assesment/Plan: Colonscopy Monday.”

Ummmm, excuse me? That’s an assessment?

No, that’s a test.

So rarely is any thought offered in the note. Now, I’m sure the differential diagnosis is well scripted in their minds. But unfortunately, it doesn’t get put to page, and there is no communication until after the test, when you may get a courtesy call from the gastroenterologist who says “Yeah, colon looked clean. A few hemorrhoids.”

Well that’s just super. But of course, you never get an inkling of what they thought was MOST LIKELY! And it’s not just GI consults. Heme consults have irritated me with the annoying “So what do you want me to do? It’s medical management.” In other words, if they can’t do a bone marrow biopsy, and it’s a boring anemia case, then good luck to you.

(Oops, there I go, talking about fellows. Must … re…sist)

But I digress. Whether it’s a fellow or an attending consult, the note should be helpful and the PCP should not be left in the dark. Please just remember we didn’t call you only to do a test. Thought MUST occur!

LACK OF POSTS

Sorry for the lack of posts. I've just started my private practice and have been a bit busy.

I have some posts brewing, including my continuing series on "Blank MD".

Stay tuned.

A LITTLE HYPOCRITICAL?

I'm probably beating a dead hrose with the whole ER thread I wrote last week, but I just want to quote PandaBear. He writes a post about drug addicts, and says that one tried to fake his way through a chief complaint of rectal bleeding. He syas:

"It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit."

So even before he checks the guy's labs, he is saying he doesn't believe he's having a significant bleed. Probably what any sane internist/primary care doc would surmise.

But Panda also says this:

"And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry"

So he drew a stat hemoglobin and hematocrit, EVEN THOUGH he figured the guy was full of garbage. Why didn't he just kick the guy out of the ER if he was so sure? Why did he send the stat labs???

Because, my friends, even the Panda knows that liability is key, and just in case the guy is NOT full of it, he has protected himself. And he's in the ER, so he has access to those stat labs when he needs them.

So for those ER-heads out there who would laugh if an internist sent such a patient to the ER (or any other patient who could use a stat lab to rule out a life threatening condition), please reflect if you would have acted any differently had you recieved the call or lab result or whatever at your office or home. Clearly, the PandaBear is making the same mistakes the primary care guys are making.

I promise this is my last post on the topic. Until I get angry again, that is.

SHOULD THESE PEOPLE GO TO THE ER?

Here are four scenarios:

1)A patient has their PCP paged at 6:30 PM, after hours, when the PCP is on the way home. They complain of diarrhea and abdominal pain that seems mild, but has not stopped.

2)An older patient comes in without an appointment and complains she saw blood in her toilet. She has felt dizzy and wanted to run in to see her PCP. But the office is swamped and she’d have to wait. There is no nurse to draw blood.

3)The lab calls with an emergency value. The potassium is 3.3.

4)It’s the weekend. The lab calls: INR is 5.

So what should a PCP do? Should he:

a)Tell these patients to wait until they can be seen
or
b)Tell them to go to the Emergency Room?

I don’t feel there is any other answer to the question than ‘B’. And I’ll tell you why. Because momma raised me to NEVER DIAGNOSE OVER THE PHONE! That is just something a doctor should not do under any circumstances. And unless the office has a nurse and a lab, as well as NG tubes, central line kits, and blood, you’d have to accept the fact that most PCP’s offices are not equipped to deal with these situations anyway.

Case one is based on an actual gastroenterologist in Florida who was told by a man’s wife he was having these symptoms. He advised Maalox and see him the following day. He ended up having IBD and dying that night. Oops. Malpractice ensued of course.

Case two is common enough. And I don’t want to personally wait on a CBC for a whole day, even with negative orthostatics, as that physical exam finding is notoriously unreliable (I can cite an ER doc who made this statement at a conference if anyone takes umbrage with that.)

Cases three and four speak for themselves. Even if I called the patient with low potassium at home and asked him to check his pulse, I’d STILL not take a chance. Same goes for the INR patient.

911doc made the following statement:

Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me. What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.

I say “Yeah, so what?" Is there something different an internist or FP could do in the office for these patients? I fail to understand the point and what should be different. What is an emergency room for? If the chest pain is even remotely possibly cardiac, that’s an emergency. At least for me it would be.

Whether the PCP shows up at the ER, whether the PCP sends a note, whether the PCP’s midlevel made the call are all complaints that have NOTHING TO DO with the point 911doc is making, which I find is false and hollow.

The fact is, is that hospital care doesn’t pay enough for the time spent. So if a PCP hasn’t placed a central line since residency, so what? An ER doctor probably doesn’t remember a lot of other things they once learned in medical school. Because they don’t need to know them anymore. And even if I placed a central line in my office, then what? I don’t have a 24 hour center in my office. Even if I ran a code, they still have to go to the hospital.

I had an ER attending tell me he wouldn’t do a paracentesis because he wasn’t covered for that under his liability insurance. The resident under him couldn’t believe it any more than I could. He probably just hadn’t done one in years. And you know what? Big deal. So I did it. And now it’s been years, and I probably would have to remember how.

Big deal.

Hey 911doc, here is your generalist. And nothing has happened to me! Your head just got a little too big.