Dr. Andy

Reflections on medicine and biology among other things

Sunday, May 15, 2005

Who are all these doctors?

One thing that can bewilder patients in an academic medical center is the sheer number of doctors involved in their care.

Let’s walk through an admission I might consult on, and go over each doctory

Say your child has a straightforward asthma exacerbation, status asthmaticus in medical argot, so you bring her to the ED. After seeing the triage nurse, maybe getting a neb (short for nebulization treatment, in this case with albuterol, which helps open up the lungs), she is shown into a room where she meets another nurse.

After waiting a while (hopefully not too long) doctor #1 comes in, talks to you and examines her. He agrees it is asthma, which you already knew, maybe mentions she’ll get more nebs and some steroids (to quell the inflammation in her lungs).

Doctor #1 is probably a resident. In a pediatric teaching hospital he could be either a pediatric resident or a resident in emergency medicine getting experience in pediatrics. He could be in anywhere from his first to fourth year of training.

45 minutes or so later, another doctor #2 walks in , listens quickly and tells you again that it is asthma.

Doctor #2 is probably the attending. She has done both 3 years of pediatric residency and 3 more years of specialized training in pediatric emergency medicine.

A few hours and several nebs later, your daughter is not doing so well. Doctor # 1 is back in and says she’ll have to be admitted. He says as soon as there is a bed for her upstairs she’ll move to the main part of the hospital and meet a new team of doctors. Since it is now 2am you wonder exactly who will be leaving the bed she’s taking

Before you make it upstairs, another doctor comes in to see your daughter. Doctor #3 says something about being another resident doing something called night float. She seems to know most of what is going on “from the chart” and is in and out quickly.

Doctor #3 is the resident assigned to admit patients overnight, so called “night float”. With new work hour restrictions (no more than 80 hours per week or 24 hours in a row) hospitals have set up all kinds of systems to comply. One of the most common is to have residents come into work night shifts, so the on-call team can sleep or take care of patients who have already been admitted. Doctor #3 is likely a 3rd year resident.

You finally make it upstairs, where a nurse asks you makes you fill out lots more forms with pointless questions about how much pain your daughter is in and whether you prefer to be told things or shown them, and you can finally get some sleep. Being a children’s hospital your chair folds out to a cot so you can sleep right next to her. You get some sleep but she needs neb treatments every 2 hours, so you keep getting woken up.

At about 8 the next morning doctors # 4 and 5 come in. #4 introduces herself as a “student doctor” and says her first name. Dr #4 refers to herself only as doctor. They says they’ll be the doctors taking care of you on the floor, which you thought Dr. #3 would be doing. Dr. #3 is home sleeping. They stay for a while, listen and then they are off.

Dr. #4 isn’t a doctor at all, yet. She is a 3rd year medical student doing her pediatrics rotations. Doctor #5 is the infamous intern, in her first year after finishing medical school. Forgive her if she seems a bit weary, in medicine we believe in learning by doing and intern year can be like drinking from a fire hose.

Before lunch, here comes #6. She is a bit older than the rest and seems a bit calmer. She says the magic word “attending” and explains she is in charge of your daughter’s care. She listens, sits and talks for a few minutes, and says maybe you can go home later, since your daughter is doing better, only needing the treatments every 3-4 hours.

Doctor #6 is the attending. She has done pediatric residency and maybe subspecialty training as well. She could be young or old, but is the ultimate one in charge of your daughters care. In many cases she would be your daughters pediatrician or one of her partners. She could be a “hospitalist” who specializes in the care of inpatients, or a subspecialist like me, roped into doing some time on the inpatient service as part of a faculty job.

Just after lunch, and by the way your daughter is up and playing now, comes doctor#7. He say hi, listens, says she sounds great, asks how long ago her last neb was (shouldn’t he know that?) and says she can go later. He tells you they want the allergists, who specialize in asthma, to come by and give some recommendations about what medicines she should go home on.

Doctor #7 is the senior resident. He is in his 3rd year of pediatrics residency and oversees the interns. He is below the attending, but makes sure everything goes well and nothing gets screwed up. He may be looking forward to private practice pediatrics next year or to further training in a pediatric subspecialty (GI, cardiology, heme/onc, etc.)

After he leaves, Doctor #8 waltzes in. She introduces herself as the allergy fellow. She asks a lot of questions about pets, carpeting, and whether your basement has mold. She also quizzes you about which medicines your daughter is on at home, how she uses them and whether she forgets to take them. She leaves, saying she’ll be back in a bit with her attending, who you thought you had already met.

Dr #8 is the allergy/immunology fellow. She has already completed her pediatric residency and is now taking or 2 or 3 more years to become an allergist. When the general

Finally, about 4PM, Dr. #8 comes in with me, Dr. Andy aka Dr. #9. I say something like “I’ve been hearing all about your daughter from Dr. #8. Sounds like she’s had asthma for a while, but it really flared with this viral infection. We’ll make some suggestions to the floor team about adding a medicine for her to use everyday to keep the inflammation in her lung under control. We’d like to see your daughter back in our clinic in a couple weeks. You can make the appointment with Dr. #8” We are in or out.

Dr. # 9, besides being me, is the attending allergist. Dr.#8 and I come to given advice to the primary team when asked. Our consults range from straightforward ones like this to more difficult ones (e.g. whether or not a patient has an immune deficiency).

An hour later comes the final Dr., #10. She notes she is just covering for the other intern, who has already gone home. She just gives you some prescriptions and paperwork, goes over some instructions and under what conditions you should bring your daughter back to the hospital and you are on your way.

A straightforward asthma admission, 24 hours and you saw 10 doctors! Imagine if your child had a complex illness or a medical mystery, requiring multiple consults. Or if you were in over the weekend and got to meet all the covering docs.

Are all these doctors necessary? Absolutely not. If instead of an august academic children’s hospital you had gone to a community hospital you might have seen as few as 2 doctors: an ED attending and your pediatrician or a covering colleague. In the community, the allergist, if called at all, would have just made some recommendations and seen the patient in his clinic. More likely, the pediatrician would have just set up an outpatient appointment.


At 11:57 AM, Blogger TexNNYC said...

More Comments on Doctors' Effectiveness

I have suffered from a relatively unknown aliment for over two years now. The frustrations that I have experienced in attempting to get a doctor to open his mind to something that he has not yet learned are becoming extreme.

I am a very intelligent person who observes subtleties, nuances and minutiae in most situations and when I decide to focus on a particular situation I can spend months speculating, on and off, without coming to a conclusion. When I arrive at a conclusion it is only after exhaustive research and eliminating all the possibilities that are close yet inadequate to explain the situation. I have always been a very adept person who is not quick to react to difficult situations with negative feelings.

I have spent the first year and a half researching my symptoms in every possible way. I have read extensively both from standard medical sources as well as from research sources. I have talked with medical persons who may in any way know something about the problem I am having. I have finally arrived at the best possible conclusion given all the facts. I am open to a better diagnosis but it would have to fit the symptoms better than my conclusion.

In these years I have discovered a fundamental truth about the more than 12 or more medical professionals I have consulted with. With the exception of two persons all the rest would appear to listen to my problems and then, and this is universal, attempt to persuade me that the diagnosis must come from what they have already learned (about the etiology of my problems). What they do end up describing does not, in most ways, fit what is occurring!

They would ignore, as though they had not heard, the parts of my discourse that did not fit their diagnosis. This response, of selecting from what I have told them that which fits their diagnosis of the moment, is so knee-jerk as to be funny if it were not that it involved my suffering.

It had to be obvious to them that I had learned a great deal about the symptoms and the possible causes for them; yet they would proceed as though I were a first grade child sitting at the feet of the wise man and explain to me that which was patently obvious as not able to explain my problem. It is at this point that I would, with diplomacy and tact, attempt to discuss with them the issues that were not reasonable in their conclusions or diagnoses or simply did not fit my descriptions. When I would point out inconsistencies or inadequacies in their analyses they would invariably appear to not hear me and consequently to not respond to these points. The end result would be that I would receive one of three responses; either annoyance or immediate referral to another physician, or both.

I cannot help but wonder how many millions of persons have suffered and even died needlessly because they presented something that the medical profession had not yet heard of from “reliable sources,” i.e. each other and medical journals and consequently did not receive the treatment that might have alleviated their suffering and perhaps have saved their lives.

I have two important things to say about this behavior:
1) That these doctors (and from my sampling I would guess many if not most other doctors) will never learn anything truly new. They may add on to the information they have stored up to that point but anything new is beyond their grasp…at least when it comes from the mouth of a patient!
2) That there is a terrible arrogance in this position that they take. Only other physicians or medical research can truly change what they have learned…certainly not something from the mouth of a once again, God forbid, patient!

I am truly deeply disgusted with the medical profession. They have chosen to ignore much of what I, the patient, have to say. When all is said and done, and what physicians appear to have forgotten or never have learned is that in spite of all the assumed effectiveness of diagnosis from test results, the best diagnosis will come from the mouth of the patient.

I continue to suffer and be insulted. It has been suggested to me that I may be delusional. I have been asked if I am seeing a psychiatrist. I have been told that what I am describing “is physiologically impossible.” How dare these people not only ignore what I am truly saying but indeed add insult to injury? And I still have not even been offered palliative care for my symptoms.

One, and just one, of the disturbing facts that come out of this situation is that since licensed physicians are the only persons who have availability, by and large, to the necessary tests and treatments that could possibly help me I end up being excluded from access to these very things which I need.

If it were up to me I would strip every physician of his license and let market forces dictate as to who should practice and who should not. This meddling in the rights of the individual ends up with an elite class who are not only arrogant but paternalistic. Do not underestimate the public’s ability, in the end, to choose the best providers both by their education and by their ability to hear their clients!

The two medical practitioners who believed me responded by saying that as they have not learned of my condition it is best to refer me on.

PS I am truly tired of hearing the argument that so often defends doctors’ behaviors: that they have lost so many potentially income earning years and, that they have put such effort in their becoming a physician. This is rot! They only have chosen their path and everything points to the fact that they intend upon making up for the lost wages! Do not make others pay for their behavior!

At 10:46 PM, Blogger Justin said...

I love lay people who think they know what it's like having gone through what we go through. Talk about being disgusted.


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