Tuesday, July 26, 2011

Don't Just Do Something, Stand There!

It's the hardest thing in the world for a doctor to do.

After all, doctors are do-ers. That is how they have managed to achieve their degrees: hard work, discipline, perseverence. Who else would be willing to memorize all those organic chemistry equations long enough to vomit them back on paper? Who else would tolerate long nights and weekends on a constant basis? But they do it because it's the right thing to do. They do it because someone has to. People don't get sick nine to five. They get sick at 2 am. And so, by it's very nature over the years, medical education becomes a sort of natural selection: only the strong survive.

Historically, doctors endure the system because they know that there are rewards for this hard work personally, professionally, socially, and financially. So throughout their training, doctors learn to perfect the art of doing. That's what people come to expect. Oh my God, doctor, he's choking: do something! He's turning blue: do something! But he fainted, doctor! Do something!

One of the best parts of medical school is learning the answers to these mysteries of medicine and how to fix them. In the past, this gave doctors a aura of deity: they could be trusted to fix just about any ailment that befell man. It was awesome. With time, a sense of invincibility and omnipotence set in.

And like flies to a flame, we bought it. Lock. Stock. Barrel.

In fact, our entire Greater Medical Complex has grown to support and promote the mystique. Doctors are the omnipotent, the all powerful, the experts, the purveyors of a great Center of Excellence, the Great and Powerful Oz's centered in the Crystal City. We have read the great CheckList Manifesto and installed the Electronic Medical Record. We believe! How much does that cost? Who cares! Just DO SOMETHING!

So imagine when a doctor says that doing nothing is the right thing to do. Man, what a Debbie Downer. There is no checkbox for nothing.

Everyone gets upset.

The patient is confused. The administration gets upset. And yes, even the doctor gets upset. But the doctor gets upset for reasons that most don't think of. The doctor gets upset because there is little incentive to do nothing. That's how he's paid. He must do something or people might sue him. It's not okay to do nothing in medicine any longer. Just like it's not okay to stop working at Walmart. We must stay busy little beavers. That's the way it is.

See Jane run. Work, Dick, work! No tickey, no laundry.

That's because doing nothing doesn't pay the bills and ancillary staff, or turn on the lights, or pay the cleaning crew, or groundskeepers. Doing nothing isn't acceptable when millions more need health care.

So imagine this scenario: a patient presents to you after a sudden self-limited, but nonetheless significant stroke. A million-dollar workup shows nothing after a week in the hospital with a normal EKG, ultrasounds, CT scans and full cardiovascular workup except an abnormal MRI that looks for all the world like a blood vessel was plugged in her brain for a period of time. She mentioned to the doctors, though, that she was told she once had atrial fibrillation so she's placed on anticoagulants and discharged. Several weeks later, she walks blissfully into her primary care doctor's office feeling fine but is noted to have an irregular pulse and EKG confirms atrial fibrillation which she didn't feel at all.

Quick doctor! Do something!

So she is sent to me to do something. I look, listen, poke, prod, review, then review some more. The patient is asymptomatic, has rate-controlled atrial fibrillation, is on an appropriate anticoagulant and medical therapy, yet there they sit, expectantly.

It would be easy to do something. If fact, it's hard not to. After all, they're not a 100 years old. They lead productive lives. We are trained to help. We are paid to do stuff. To order. There simply is no tangible incentive to do otherwise.

And yet, sometimes, despite the powers that be, the best thing to do is nothing. Just stand there. Take the medicine. Breath deep. Move on. No need for more studies or repeat studies. No need for catheter ablation or additional medications to control the rhythm. Really.

But you'd better be damn good at explaining why, lest the legal world come back to bite you where it hurts. So minutes upon un-billable minutes are spent explaining the options and the reasons why, all for a small "thank you for taking the time." They seem grateful leaving, but you wonder, are they? Or will they seek the answer they want to hear somewhere else?

I wonder.

Truth be known, in our system is is always easier and more lucrative to do something, but the best doctors I know are the ones who are willing when it's appropriate to place their necks on the line to say enough is enough.



Lisa said...

I have a small cancerous tumor in a lymph node. It is a slow growing lymphoma that I will most likely die with rather than of. It probably would not have been found except being a breast cancer survivor, everything gets checked out regularly. When it was found, my oncologist explained it to me and we decided to do nothing. I could have had surgery to remove the lymph node, but why do that for something that is innoculous? I needed my doctor to explain it to me, because the word lymphoma scared the holy hell out of me, but once I understood it I was fine with the decision. Your patients can understand the common sence to do nothing. She might be like me, very happy to have a doctor who won't kill a fly with a sledge hammer.

Tim said...

A 62 yo man was a patient I had seen several years ago regarding a parotid gland tumor. FIne needle aspiration suggested a Warthin's tumor– a benign growth which is a thick-walled cyst with no malignant potential. He had a history of multiple MI's in the past and was not working because of his heart disease. I suggested that we simply watch this, as cancer was not a concern, and a three hour operation under general anesthesia would pose a significant risk to his heart. He agreed and left. He came back about 3 months later begging to get the tumor removed because it was causing significant pain. I reminded him of the reason we deferred before, but he wanted to risk it. These tumors can increase in size and cause significant pain. He was taken to the OR understanding his chances. On induction of anesthesia, bradycardia led to cardiac standstill from which he did not recover. He hadn't been quite honest with his family, whom he never brought to a consultation, about the extent of the operation ("just a little operation on my neck"), but with a little discussion, they understood the situation. I attended his funeral, which was packed to overflowing into the church yard with people this man had helped with things like transportation, etc., which he could do even with his heart disease. So, why did I still feel so bad about this?
A great deal of Plastic Surgery is talking people out of the latest procedure they saw on Good Morning America last week. I've learned to be comfortable saying, "I can't do this on you," followed by why.
I am currently trying to talk another 62 yo patient with a Warthin's Tumor and significant heart disease out of having a parotidectomy. He is having NO problems! He asked if it was OK to talk to his cardiologist about it, and see if he thought it would be OK to have the operation (as if he needed to ask me). I have found cardiologists to be quite liberal with their clearances for patients that worried me, but what do I know? I'm just a surgeon!

TIm said...

There'll be more "doing nothing" in Britain, now:


Adam Nally, DO said...

Superb. Thank you. I think I will just stand here a while . . .

Dr Skeptic said...

Thanks. Completely agree.
The problem is even worse in surgery. My colleagues often say that it is easier just to book patients in for surgery than to spend an extra 20 minutes trying to explain why they might be worse of with an ineffective invasive procedure. And that is without the financial incentive, reputation incentive, referring doctor's expectations, etc. Plenty of examples at doctorskeptic.blogspot.com