Shameless plug: David Mayer & Co over at Educate the Young were kind enough to give me a shout-out for some of the patient safety work I did after attending the Telluride Patient Safety Summer Camp last year. Great organization, great staff and great experience. Can’t speak highly enough of these guys.
Category Archives: Medicine
Clancy Martin recently published an article in the Atlantic titled “Playing with Plato,” in which he both reviews Rebecca Goldstein’s new book Plato at the Googleplex (which I have not read) and argues that the philosophical questions confronted by the historical philosophers are still relevant to modern day life (a point for which I have great sympathy). To me, however, the most interesting part of his article was the first sentence:
“When I was 21, I was trying to decide whether to become a doctor or a philosophy professor.”
He goes on to explain that, during this process, he got two conflicting pieces of advice. From his business-minded brother: “Be practical. Books are dangerous things. Just because it’s on paper, you think it’s true.” And from his “New Age guru” father: “Be a professor. You’ll never be rich, but you’ll be doing what you love: reading and writing. You get summers off. It’s a good life.” In the end, Martin followed his father’s advice and, by all accounts, has achieved a far bit of professional success.
Understanding why I was fascinated by this brief introduction to Martin’s article requires a little background: when I was 22, I walked away from four years of undergraduate study (read: obsession) and an offer to attend a Ph.D. program in Boston to return to school and become a physician. It wasn’t an easy choice. I suffered through more than one sleepless night. I sought a lot of advice. Much of it was in line with what Martin relays: “You’ll never find a job” versus “Do what makes you happy.” In the end, I found that, unlike Martin, neither of these lines of reasoning was, well, reasonable.
What eventually caused me to I walk away from academic philosophy was, ironically, philosophy itself. For me, books were indeed dangerous. But they didn’t ruin my sense of practicality and worldliness, as Martin’s brother feared. Rather, they shattered the idyllic vision I had of my career, lounging in the quad reading Spinoza and taking research trips to Greece. I imagined that what drove me was the possibility of changing young minds via the lectern and the pen. But the more I thought and the more I struggled, the more I realized that my motivation to enter academic philosophy was exactly as Martin’s father suggested: I wanted to spend my life reading and writing and I wanted someone to pay me for it. Instead of being a noble pursuit, entering academic philosophy was the most selfish thing I could imagine doing.
Why did this bother me so much? Most careers are chosen for selfish reasons; they offer money or power or respect or some other end. Time and time again, however, I returned Plato’s allegory of the cave and its enduring mystery: why, after climbing to the surface and seeing the beauty of the sun, would the philosopher return to the darkness of the cave and the danger of trying to free others? To me, this is similar to the great paradox of Buddhism: the quest for detachment from the worldly cycle of desire and suffering requires us to be moved with compassion for those around us.
My mentor, Frank Harrison, helped me see that the answer, first, last and always, is love. The kind of love that drives us upwards towards Martin’s “eternal idea” should also drive us outwards towards our fellow man, who, in the words of Marcus Aurelius, “participate in the same intelligence and same portion of divinity” as we do.
So why couldn’t my work with students and colleagues be my expression of this philosophical love? Because, by and large, they would be exactly like me: upper-middle class Caucasian males. Instead of practicing love for the other, I’d be practicing self-love under another name. Further, a long, hard look at academic philosophy lead me to conclude that being a philosophy professor and being a philosopher were distinct enterprises. Often, they can even be opposed. Recent events at the University of Colorado, Northwestern and Miami have only reinforced my belief that modern academic philosophy is a troubled system.
All this being said, I will not pretend for a moment that leaving philosophy for medicine was an act of self-immolation. The decision was difficult, but the human body is fascinating and medicine is challenging. I find the work fulfilling and am consequently no martyr. But this, I would argue, is the great genius of the Greeks and, perhaps, the idea we should most strive to reclaim: serving yourself and serving others are not mutually exclusive, but rather walk together like two feet. In the end, I left academic philosophy because I believed that I would not be happy there. I believed that becoming a physician would make me a better, wiser person. And, trying my best to love wisdom, what other choice could I make?
I first heard about the ICD-10 when I was working at a small start-up, trying to develop an EMR for a string of dialysis clinics. It was always spoken of with a certain gravity, like the ominous visit from an aunt that nobody in the family likes, but feels obligated to see. Practical (read: business) people hate ICD-10. It’s giant and unwieldy. Doctors think it’ll be an excuse to bilk them out of payments. They dread the day that they get a “false coding” note for a visit for a broken arm because they didn’t specify the patient fell off their bicycle or down a flight of stairs. So who’s driving this?
I can only assume that it’s research. ICD-10 must be an epidemiologist’s dream. Want to prove something inane, like the fact that waterskiing accidents are more common in the summer? ICD-10 is your tool. If you can collate all the insurance billing from the entire country, you can begin to pull out these vanishingly rare instances and analyze them. Admittedly, as this article points out, some of the events the ICD-10 tries to capture are so vanishingly rare that they actually, well, vanish. They’re literally unheard of or actually impossible. But what about some of the other widely panned codes, like falling off a chicken coop? Theoretically, we could begin to perform real time monitoring of safety conditions in all kind of industries. These events are rare, which means that if we see a cluster of them occurring in a particular geographic area, an investigation might be warranted. Maybe building inspectors aren’t performing their inspections. Maybe a certain company isn’t enforcing proper safety standards. Again, theoretically, the giant index of ICD-10 codes could drive meaningful data collect and interventions.
The problem is the observer. Inter-observer variability is a problem in all sorts of medical fields, from reading chest x-rays to interpreting physical exam findings. For the ICD-10 to be useful for research, you need to code these rare events correctly. And, with the endless array of options, the chances of this happening seem, to me, to be vanishingly small. Maybe there’s a good technical solution to this, where an EMR scans the HPI and offers a variety of appropriate billing codes (writing “chicken coop” should be a dead give-away). The validation and implementation of this for all 155,000 codes is, however, a monumental task at best. Such an undertaking can (and should) be done by those who created the codes in the first place. Unfortunately, something tells me they can be less than thorough.
I recently had the opportunity to attend an event by my institution’s human-centered design group. With escalating penalties for 30-day re-admissions on the horizon, they’d been charged with finding a way to bring our rates down. Like any set of Lean-trained professionals, they began delving into the chain of causes leading to patients bouncing back into the ER (i.e. the “5 Whys”). Their thought process was: We’re having too many 30 day re-admissions (why?). Because patients are missing their follow-up appointments (why?). Because they can’t arrange transportation (why?). At this point, two different threads emerged. On the one hand, public transport wasn’t sufficiently robust to deliver the patients to their appointments and take them home in a timely manner; on the other hand, patients had trouble arranging rides home because clinic appointments tended to run late and they never knew when they needed to be picked up. The latter is a process-centered, Lean-friendly kind of problem (and can be addressed as such). But what about the former? The logic was that “Either through re-admission penalties or taxi vouchers or some other way, we’re paying for these patients inability to find adequate transportation. So why not do it directly?” So the presenters began a pilot program providing transportation to patients who couldn’t find a ride.
Note that we only got “3 Whys” deep before we lost the distinction between the responsibilities of the healthcare system and the responsibilities of society at large. Since many hospitals are public institutions, I don’t believe this is necessarily wrong. However, we need to acknowledge the uncomfortable position this puts us in. The medical-industrial complex already plays a large role in our lives. By expanding the explicit responsibilities of healthcare organizations, we also expand their responsibility for the (generally unspoken) social determinants of health. Doing so creates redundancies and conflicts between different healthcare organizations and between healthcare organizations and the social support systems they try to supplement. Competition drives innovation, but economics of scale drives efficiency. The question is: how de we find a balance between the two?
The New York Times published an article titled “A Life-Death Predictor Adds to a Cancer’s Strain” or, alternatively, “Genetic Test Changes Game in Cancer Prognosis.” The piece is interesting on several levels, but, to me, serves to highlight an increasingly common ethical conundrum: are physicians obligated to seek knowledge that is available but has no possible medical benefit?
Most of us are familiar with the Schrödinger’s cat thought experiment (the basic setup: a cat is placed in a box, along with a device that has a 50/50 chance of killing it within the hour). Suppose Schrödinger decided to actually carry out this experiment and you happen to be the veterinarian for the poor soul whose cat he borrowed. Having been rushed to the scene by a distraught owner, you are faced with a choice: open the box and reveal the cat’s present state of health or wait and let the cat reveal itself by its eventual demands to be let free (or lack thereof).
Where my story runs parallel to real life: at the point of decision, Schrödinger’s veterinarian and the physician have no power over the patient’s outcome. Their professional capacity as healer has been exhausted. The cat is either dead or alive. The patient has Class 1 or Class 2 ocular melanoma (and its attendant mortality). Until the proverbial box has been opened, however, neither state of affairs has quite come to pass. The patient is neither doomed nor saved. The physician stands as the portal of knowledge, holding the key that could dispel fear but also kill hope.
Typically, patients just want the good news. In a perfect world, only patients with the treatable Class 1 melanoma would have the test performed. Their Class 2 counterparts, on the other hand, would avoid it and preserve their hope until the end. Unfortunately, this perfect world requires physicians with prescience (or an ethics “flexible” enough to perform the test without the patient’s knowledge).
What, then, of our imperfect world? Is the possibility of relief worth the risk of a death sentence? Further, what is the physician’s role in answering this question? It is my belief that the option must be presented. The decision to know or not know is deeply personal. Once he has stepped outside of his role as healer, the physician has no expert knowledge to justify any form of paternalism. While he can serve as counselor, interpreter and friend, the physician has no right to decide if the possibility of finding a dead cat is worse than waiting next to a terrifyingly silent box.
I have no doubt that Lewis Blackman was a wonderful young man. He beams out of all the pictures included in The Faces of Medical Errors, a charismatic, good-looking teenager. Despite our tendency to deify the dead, I have no trouble believing all of testaments to his intelligence, character and joy. Based entirely on the courage and poise of his mother, I’m sure all of the praise heaped upon him in the opening minutes of the video cannot begin to touch the reality of his potential as a human being.
And yet, as these accolades rolled on, I felt a growing annoyance pulsing in the back of my skull. The purpose of the film was to viscerally connect us to the consequences of medical errors, to strip away the comforting veneer of facelessness from patient safety lapses and give us a regrettable casualty we could fixate on. As I gazed at the pictures of Lewis floating by, I couldn’t help but wonder if the video was unintentionally striving to sell us on the “regrettable” part of the formula. Lewis could have been my little brother. He was athletic, talented Caucasian male born to educated parents who entered the hospital for an elective procedure. Despite our best efforts, race and class are difficult to eradicate from our visceral reactions. Even as I was moved nearly to tears by the Lewis’s story, a dissenting voice was growing in strength
What if Lewis had been a poor African-American boy, in the hospital for a sickle crisis? Or a homeless person, in the hospital for an OD? Or an undocumented immigrant, in the hospital giving birth? Or a teenage drug dealer, in the hospital for a gunshot wound? Especially in light of recent events in Florida, it is difficult to argue that, as a culture, our assignment of blame is unbiased. Rationally, I believe that the death or injury of any patient due to a preventable error is inexcusable. Each is equally a tragedy. But I cannot with perfect honesty claim that any of the stories above would impact me the way Lewis’s did (I am interested if any of my colleagues here at Telluride with more diverse backgrounds feel differently. Do I only care so asymmetrically about Lewis because, to paraphrase President Obama, “ten years ago, Lewis Blackman was me”? Please let me know your thoughts on this.). The realization made me equally sad and angry. I was angry that the film was pulling strings whose very existence filled me with shame.
This is not, however, meant to be an analysis of class relations. I’m writing about this internal struggle because of the revelation that followed on its heels. Lewis was, by most estimations, a child of privilege. While this does not make his death any more tragic, it does make it more problematic. Lewis entered the hospital with powerful advocates who, while not medically trained, were educated and assertive. If Lewis, backed by a mother who understood what his vital signs meant and was unafraid to speak up for her son, could fall victim to a harmful medical error, what chance do the indigent, the elderly and the handicapped have in our medical system? What a call to action this is! Our methods of healthcare delivery are capricious to the point of transgressing our normal social constructs. This realization allowed me to harness the emotional power of Lewis’s story to remind myself that Lewis, compared to hundreds of other patients in the hospital that day, had an excellent chances of walking out unscathed. Scores of more vulnerable patients are exposed to the same systems that caused his tragic. If we truly hope to do no harm, Lewis’s story should serve as a constant reminder of how far we have to go to protect all of our patients, regardless of the situation into which they were born.