Medical School 2020, Year 3, Week 26

Week 2 on family medicine rotation. Monday morning begins with a one-hour lecture by a 53-year-old talkative palliative care specialist (“helping patients learn how to live with serious illnesses”).

Palliative care was recognized as a speciality by the American Medical Association in 2008. “The profession has exploded since insurance realized that palliative care consultations save money. The problem is we don’t have enough fellowships to meet the demand.”  She would like her colleagues to be involved with CHF, COPD, cancer treatment, dialysis, and dementia when a patient has a life expectancy of less than 18 months. She adds, “We are far behind Canada with integration of palliative care into medical management. For example, palliative care specialists are typically at every Canadian dialysis and heart failure clinic.” Why is the U.S. lagging? “Political motivation,” she responded. “Palliative care became known as the ‘Death Squad’ created by ObamaCare.”

In the old days, every physician was considered qualified to educate patients and families about the logistics and prognostics of different care options, e.g., whether to agree to surgery or proceed with intubation in a terminal disease. Now the conversation gets punted to a credentialed separate specialty: “We also investigate the reasoning behind a family’s decision, we sometimes just listen but we can also use evidence-based methods to guide a patient to a more informed decision,” she explained. “For example, a 27-year-old polysubstance user got into a car crash. The ICU team doesn’t want to intubate because they fear it is unlikely the patient will ever be extubated. The mother wants the whole nine yards. We came in to talk to the family for goals of care and learned that the mother’s insistence was driven by a fear that the son was going to Hell. We coordinated chaplain services and eventually the mother agreed that it was time to let the son pass away.” (Hospitals have a substantial financial incentive to bring in palliative care specialists, who can bill more per hour than an internal medicine (hospitalist) physician.)

Roughly 80 percent of the time, she is discouraging patients from opting for expensive yet low-value procedures. In some cases, however, it is the palliative care doctor who pushes for a procedure: “A 38-year-old male had multiple life-threatening injuries including spinal cord compression and blunt abdominal trauma leading to a partial colectomy and colostomy after an industrial work accident. He was in constant pain. His neurosurgeon recommended against spinal cord decompression due to the high risks of surgery. We recommended he undergo it even though it would likely worsen life expectancy because the family and patient could not bear to see him in so much pain.”

Farmer Fiona and I happen to be assigned to palliative care for Monday, so after the lecture we head over with the attending to the palliative care team room. Each of us sees two patients. I sit in on a family meeting concerning a heavily sedated 69-year-old male with COPD and congestive heart failure in the ICU. The family has been debating for three weeks whether to stop the pacemaker that is keeping the patient alive. The wife is tearful, but says it is what he would want. “He wouldn’t want to live like this in the hospital.”

[Editor: It is always the spouse who wants to pull the plug, citing a never-committed-to-writing desire to be dead rather than sick, and the kids who want to keep a parent alive. Keep that in mind when setting up a health care proxy.]

After the meeting, we call the cardiology service. Some providers and device manufacturer representatives are hesitant about stopping the life-saving device. “One of the cardiologists on the service refuses to do these types of procedures,” says the attending, “but the one on tomorrow understands.” The manufacturer rep pushed back, but eventually relented after discussion with the cardiologist. We scheduled the shut down for the next day. This would allow the family from out of town to be present for the patient’s final hours. 

I join the attending for a new patient in the neurotrauma ICU. The 67-year-old male recently had a car accident and was coded for 10 minutes until a pulse came back. We don’t know anything about neurosurgery and haven’t talked to the patient’s neurosurgeons, but we have read some notes in Epic and supposedly have expertise in how to break bad news to patients. We had a (necessarily) vague conversation that might have helped the family formulate some questions for the neurosurgery team and most definitely helped the hospital collect revenue from Medicare.

Tuesday: family medicine clinic. The first patient is a 43-year-old father of two and aircraft mechanic for UPS presenting for an annual checkup. We discuss indications for statins given his 10-year cardiovascular risk above 7.5 percent. We prescribe Lipitor and counsel regarding smoking cessation. He mentions job-related back pain. Doctor Dunker performs a brief strain/counter-strain OMT technique. “What I really need is a massage from my wife.” Doctor Dunker jokes:,”Want me to write a doctor’s note?”

During annual visits, we evaluate USPSTF (United States Preventive Services Task Force, a panel of experts appointed by the Department of Health and Human Services) Grade A/B screenings and CDC vaccine recommendations. We often have a discussion about the new shingles vaccine, Shingrix. Our office does not carry the vaccine, which costs $100 at a local pharmacy and Medicare Part A or Part B do not cover this. Patients on whom taxpayers are spending $10,000 or more annually balk at the idea of paying $100 dollars to cut their risk of getting shingles from 33 percent to about 1 percent.

Doctor Dunker recounts several patients that have permanent life-altering complications from shingles, namely postherpetic neuralgia. “I had a retired nurse commit suicide because of the intense pain. It is just like trigeminal neuralgia.” (Also known as the “suicide disease”, trigeminal neuralgia is a chronic pain disorder with recurrent episodes of intense, unexpected jolts of pain on one side of the face that last for a few seconds.)

I sit in on a visit for a 68-year-old female active smoker with congestive heart failure (CHF) who does not understand her disease. She arrives with a “care coordinator,” a nurse with extra training whose job is to prevent hospital readmissions and reduce the chance that the hospital will get dinged by Medicare under the Readmissions Reduction Program (RRP). She has had two CHF exacerbations requiring readmission due to a lack of understanding of her medications and when she should take her “fluid” pill to avoid becoming volume-overloaded. I use her chest x-ray from the most recent admission to explain why she’s becoming short of breath and  say that we will likely need to increase her metoprolol dose to control atrial fibrillation and keep her heart rate below 110 beats per minute. Her INR (international normalized rate, a measure of blood clotting when on Coumadin) from today’s in-house blood draw was increased. I told her that the hospital’s latest amiodarone prescription may be responsible. I feel like I am getting the hang of outpatient medicine!

Thursday afternoon: playing around with Epic and notice an InBasket message, which I hadn’t realized we have access to. Who would send me something in this? It is a request from Doctor Dunker that I look up ectopic kidney (kidney located in the pelvis). I do research on UpToDate.com and present findings to Doctor Dunker to help him prepare for a meeting with a family and their newborn. I explain the main considerations in management of ectopic kidney are: (1) risk of hydroureter/hydronephrosis,  (2) association with other congenital anomalies, and (3) increased risk of urinary tract infections

Doctor Dunker takes responsibility for his patients, a contrast to the hospital’s poor continuity of care. For example, on Friday morning, we see a 72-year-old female who was admitted to the hospital the previous week for a GI bleed. The patient was stabilized on IV fluids and 2 prbc. The EGD showed no abnormalities, but because the patient stabilized a colonoscopy was not performed. She now has to wait several weeks for an elective colonoscopy. After several thousand dollars in hospital bills, still no answer. No ownership.

[Editor: It’s not all bad. Via the above incident, the hospital obtained “ownership” of several thousand tax dollars via Medicare!]

Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night. Twelve classmates drive 30-minutes outside town to a new, dog-friendly brewery.

The rest of the book: http://fifthchance.com/MedicalSchool2020