My First Day on the Job …

There has been a great deal of discussion about doctors’ in training work hours and work load. In June of 1976 I reported to the Jackson Memorial Hospital complex three days in advance of my start date for orientation. I was given a tour of the facility, filled out countless forms and waivers, received my ID badge and was ultimately sent to the Department of Medicine to receive my assignment.

Sitting in the conference room and looking at the patient assignment and ward team assignment list I found myself at the bottom of the list. “Elective Rotation – Steven Reznick MD Neurology.” While all my colleagues in the internal medicine training program left to meet their new residents and meet and learn their patients I was sent to the neurology department in the next building to perform neurology consultations. When I got to the Neurology Office the Chief Resident laughed at me. “Reznick you are on elective. There is no night call. You start in three days. Go home and enjoy your last three days of freedom. Be here at this office at 9 a.m. and we will see what if any consults we have to do.”

Three days later at 7 a.m., filled with anxiety, I arrived at the neurology office which was locked and closed. At 8 a.m. a secretary arrived, showed me where to sit and I waited. At 8:50 a.m. no one had arrived yet on the medical staff and she received a phone call. “Dr. Reznick that call was from your chief resident in Internal Medicine. He needs to see you now in his office.” I asked directions on how to get there and off I went.

The Chief Resident had just completed his three years in internal medicine and was now entering an administrative and research year. He greeted me with, “Reznick I am not sure how you managed to be so unlucky but I have to reassign you from elective to Ward Team III on South Wing 8. You have eighteen patients on your service and you do not have the luxury of three days to learn them. By the way, here is the team pager and you are on call today and tonight.” “How did I get so lucky? “ I asked. “We originally had an anesthesia resident rotating through medicine but he decided after orientation that he did not want to be a doctor so he just left.”

The Chief gave me directions to SW-8, which was at least air conditioned, and off I trudged. Upon arrival I went to the nursing station, introduced myself to the charge nurse and asked if my ward team was around. “They are not back from morning report yet but we need you in 828. The priest arrived fifteen minutes ago and they are waiting for you to terminate life supports.”

My first patient was 28 years old with widespread metastatic terminal breast cancer. After multiple seizures from brain metastases and an unsuccessful CPR attempt she was “brain dead” on a ventilator. Her family had chosen to terminate life supports and my role was to walk in, disconnect the ventilator and pronounce her dead when she stopped breathing. I walked in, introduced myself, shook hands all around and listened to the family talk about my new patient. When it was time the nurse and priest walked to the ventilator and disconnected it with me holding my hands so I did not feel like I was doing this alone. The nurse adjusted the morphine drip and the patient peacefully and calmly ceased breathing. I listened for a heartbeat, felt no pulse, saw no respirations and spoke to each family member and the priest as my pager screeched, “Call 4125 MICU for a transfer.” I found a phone and called. AC, an intern said, “Hi Steve. We are transferring a 23 year old with rhabdomyolysis and acute tubular necrosis (kidney failure) just off peritoneal dialysis with calcium of 16 out to the floor because we need a bed for a younger more salvageable patient. Can you come get him please?”

The charge nurse on SW-8 gave me directions to the MICU and it took me five minutes to walk there. Out in the hallway was a large stretcher with an even larger gentleman on it with two IV lines running almost wide open and three volumes of charts each larger than the Encyclopedia Britannica. There were no transporters or orderlies to move the patients at this large public hospital so I was left to push the bed along the course I had just walked to get back to SW-8. We walked through non air conditioned East Wing which was considerably more difficult pushing a stretcher than on the original trip.

On the way I introduced myself to Frank, my new patient and began to take a history. Poor Frank was a furniture mover who developed a fever and chills while moving a piano up some stairs and, when he got home and went to bed, had terrible muscle pain. He was too weak to get up so he called 911 and was brought to the hospital three months earlier. For some reason his muscles had decomposed due to the infection, heat and bad luck. The dissolving muscle enzymes were like molasses as they passed through the filtration of the kidneys clogging them up and sending him into acute and life threatening kidney failure. He had survived dialysis and infection and was now being bumped out of the unit for a “younger more salvageable patient.”

When I got back to SW-8 and placed him on his bed I sat down with his chart, overwhelmed and considered using the same option that the anesthesia resident had exercised. I was reading and crying when I felt a hand on my shoulder, looked up and my new resident introduced himself. “You have had a tough morning. Let’s go to the blackboard and talk about hypercalcemia and how to treat it. I bet you know far more than you think you do. I have you covered, don’t worry.”

We were almost through his chalk talk and were about to examine the patient when the beeper screeched again. “Please call 4225, the ER. We have a GI bleeder and he is your admission if he doesn’t arrest before you get here.” John, my resident, jumped up and screamed, “Follow me.” He was running full speed, down the stairs and towards the ER. It was a ½ mile run if not more. When we arrived, sweaty and panting for breath we noticed a jaundiced man surrounded by doctors and nurses with blood spurting upwards from his mouth like an oil well that had just been opened wide. John pushed them aside, felt for a pulse and said to me, “Start CPR.” I got up on the stretcher and started compressions with each compression producing a geyser of blood out of his mouth and on to my white coat and clothes. There were no goggles. There was no barrier protection. “Stop compressions, “he ordered. “There is no pulse or blood pressure, let’s call it.” “Time of death 9:55 a.m.” John directed me to the chart where I wrote a brief note, called the next of kin and informed them and then changed into clean scrubs. “We have about an hour or two now before another admission so let’s go back to the floor, finish up with your surviving patient and get to learn the others.”

At 7 p.m., having rounded with me on all my new patients, John asked me if I had eaten all day and did I live alone. I told him I had not eaten anything since coffee in the neurology office and I was married. He suggested I call home and tell my wife that I wasn’t coming home that night. “Let’s get you to the cafeteria, get you some nourishment and let me introduce you to the resident covering you and Dr Homer tonight.” Since I was not assigned to patient care at orientation, I had not been issued meal tickets. I had about five dollars in my wallet so John gave me some of his meal tickets for a meal. John was a saint. My covering resident was his equal. “Pat” called me a “thoroughbred stallion who needed to be brought along slowly.” She gave me her pager number and told me to call her if I got an admission or if I had a patient care issue. The two other interns on our team were excellent. They made me a summary of their patients and wandered home at about 8 p.m.

The time from 8 p.m. until 3 a.m. was a vast blur. There was an admission of an elderly gentleman with pneumonia. It required drawing all his bloods, labeling the tubes and carrying them to the lab. I had to wheel him to x-ray for a chest x-ray (there were no CT Scans yet), obtain a sputum specimen and gram stain it for Tuberculosis. There were the three blood cultures to draw, starting the IV line and antibiotics and of course writing the admission note and orders and dictating them. There were countless calls from nurses about infiltrated IV lines to be restarted, headaches, fevers requiring me to show up and draw blood cultures, family members calling to discuss their loved ones status.

At 2:30 a.m. I wandered into the ER because I was up for the next admission. “Pat” looked at me and said, “Go into the lounge, lie down and take a nap. Give me your pager. If anything comes up I will wake you. You need a nap.” That simple act of kindness and consideration and a 30 minute nap was like a shot of Café Cubano and adrenaline and, when 7 a.m. work rounds began with my ward team back on site with my resident John, I was relatively fresh to face a new day. I passed the pager to Phil, the other intern, as he asked me, “How did it go?” Somehow I mustered up a “No sweat especially with resident coverage from John and Pat.  John is covering you tonight so I expect you will be fine!”

We got very little sleep during my internship (PGY1) and residency training. We worked 100 plus hours weekly. The patients we saw were mostly severely ill and complex. We did all the lab work ourselves in the ER house staff lab. We started all the IV’s, drew all the bloods, and transported the patients ourselves. The work was physical, demanding, cerebral, emotional and exhausting. Every new patient was seen by an ER physician and attending, an intern, a medical student, a covering resident.

They were reassessed at 7 a.m. on work rounds with your resident and ward team plus often the chief resident. At 9 a.m. you presented the new admissions to a faculty member and the entire residency class at morning report. At 10 a.m. you presented the case to your team attending physician on attending physician rounds. This faculty member reviewed the case, examined the patients and wrote a note documenting agreement with the care plan. At noon your resident presented the case to the Chief of Staff at Chief of Staff Rounds. By 1:00 p.m. the problems and decision making had been reviewed and discussed by six or seven physicians. Sleep was not an issue in decision making because we had so many immediate layers of patient decision making reviews.

Our overworked supervising residents for the most part were caring and helped us out if we were exhausted or in over our heads. Our chief residents were available around the clock if we needed extra help.

I do not want today’s doctors to have to work as hard and perform the menial tasks that I was required to do for any reason let alone because I went through it and survived. I do not believe that the layers of supervision and questioning of your decisions allows for sleep deprived errors and mistakes if everyone is doing their job appropriately. I do feel fortunate that I learned to stain specimens and look at them under the microscope and run electrolytes on flame photometers and learn how to set up cultures of blood and urine on culture plates then read them. It taught me the time involved and the limitations of the test plus the margins for error.

I do believe the high volume of severely ill individuals I cared for broke me down and made me a dehumanized efficient machine. I was fortunate that caring faculty built me up and reminded me why I went into this profession to begin with.

Last week a prospective new patient came by to meet me at my office and see if he wanted to join my practice. During the discussion he lifted his shirt and showed me some scars on his abdomen. “You don’t remember me? You gave me those scars inserting catheters to do peritoneal dialysis on me on SW-8 on your first month as a doctor. I remember how frightened you were that you would hurt me or kill me. I was suffering from kidney failure and high calcium after my muscles broke down from an infection. You treated me for six weeks after I left the ICU and transferred me to an acute rehabilitation hospital where I learned to walk again. I live in this area now and I found you on line and want to be your patient again.”

It’s incredible how life always seems to come around full circle!

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To Floss or Not To Floss? Making Recommendations Without Data

The U.S. Department of Health has announced that there is no data that flossing your gums has any benefit.  This has led to an Associated Press review of the paucity of randomly controlled trials with evidence that flossing is beneficial. The result is a new recommendation that flossing daily is not necessary. We are living in an era where the only justification for research and observational studies seems to be to justify saving money by not teaching patients something or encouraging them not to do something. Cost containment is the key as the US Government tries to lower the percentage of dollars spent on health care as a percentage of the Gross National Product.

Experts at the Cleveland Clinic spurred on by the “Bale and Doneen” philosophy that inflammation in arterial vessels leads to acute heart attacks and strokes have pushed for greater periodontal care and health. Flossing is part of that philosophy. Cleaning in-between your teeth with hand held pics or water pics provides cleaning of the gums and spaces between teeth as well.  There are few or any studies on this subject because the benefit is so obvious that there has been no need to perform them.  Dentists assure me that proper tooth and gum care is essential to your general health and wellbeing.  This is common sense like not crossing a busy street against the light, not drinking alcohol and driving a car or truck or not jumping out of an airplane without a parachute. It’s time for our dental schools to organize and perform these studies but I suggest you keep caring for your gums and teeth while the data is being accumulated.

Pneumococcal Vaccine in Development May Fight All Strains of the Disease

Community acquired pneumonia (CAP) plus other infections attributable to the Pneumococcus bacteria account for 15 million infections per year including pneumonia, meningitis and bronchitis. The organism is the leading cause of death in children less than five years old.  Over the last 30 years pharmaceutical companies have developed Pneumovax 23 which covers 23 unique bacteria that cause CAP in adults and Prevnair 13 which covers 13 pneumococcal bacterial strains.  Twelve of the bacteria in Prevnair 13 are identical to the Pneumovax 23 with only one unique bacterial type included.

A group at the State University of New York at Buffalo led by Blaine Pfeifer, specializing in chemical and bacterial engineering; has developed a new approach to pneumococcal vaccination. Working with computer modeling and animals to this point, they have developed a successful vaccine that attacks pathogenic pneumococcal bacteria while leaving the beneficial and non-pathogenic subtypes alone. The vaccine reads proteins on the surface of the bacterial cells and destroys only those that show aggressive activity. The vaccine has been 100% effective against the 12 most virulent pneumococcal bacterial strains existing in animal studies.    The vaccine is being prepared for human testing in the near future.  The preliminary work was discussed in the medical magazine Medical Economics

How Tightly Should We Control Blood Pressure in the Elderly?

A recent publication in a fine peer reviewed medical journal of the SPRINT study proved that lowering our blood pressure to the old target of 120/80 or less led to fewer heart attacks, strokes and kidney failure.  There was no question on what to do with younger people but to lower their blood pressure more aggressively to these levels. Debates arose in the medical community about the ability to lower it that much and would we be able to add enough medication and convince the patients to take it religiously or not to meet these stringent recommendations?

There was less clarity in the baby boomer elderly growing population of men and women who were healthy and over 75 years of age. The thought was that maybe we need to keep their blood pressure a bit higher because we need to continue to perfuse the brain cells of these aging patients.

A study performed in the west coast of the United States using actual brain autopsy material hinted that with aggressive lowering of the blood pressure, patients were exhibiting signs and symptoms of dementia but their ultimate brain biopsies did not support that clinical diagnosis. In fact the brain autopsies suggested that we were not getting enough oxygen and nutrient rich blood to the brain because of aggressive lowering of blood pressure.  Maintain blood pressure higher we were told using a systolic BP of 150 or lower as a target.

A recent study of blood pressure control in the elderly noted that when medications for hypertension were introduced or increased a significant percentage of treated patients experienced a fall within 15 days of the adjustment in blood pressure treatment.  This all served as an introduction to a national meeting on hypertension last week during which the results of this same SPRINT (Systolic Blood Pressure Intervention Trial) strongly came out in favor of intensive lowering of blood pressure to 120/70 to reduce heart attacks, strokes and mortality in the elderly and claimed even in the intensive treated group there were few increased risks.   On further questioning however by reclassifying  adverse events in the SPRINT trial to “ possibly or definitely related to intensive treatment, the risk of injurious falls was higher in the intensive vs conventional treatment group.”

What does this mean in the big picture to all of us?  The big picture remains confusing.  It is clear that lowering your blood pressure aggressively and intensively will reduce the number of heart attacks and strokes and kidney disease of a serious nature.  It is clear as well that any initiation or enhancing of your blood pressure regimen puts you at risk for a fall. You will need to stay especially well hydrated and change positions slowly during this immediate post change in therapy time period if you hope to avoid a fall.  Will more intensive control of your blood pressure at lower levels lead to signs and symptoms of dementia due to poor perfusion of your brain cells?  With the SPRINT study only running for three or more years it is probably too early to tell if the intensive therapy will lead to more cognitive dysfunction.

Antibiotic Associated Colitis Increases Risk

At least a half dozen times per week patient’s call with symptoms of a viral upper respiratory tract infection or present to the office for a visit with symptoms and signs of a cold.  These illnesses are caused by small viral particles which do not respond to antibiotic treatment.   Your body’s defense system attacks these viral particles and over a period of hours to days defeats them.   Despite years of ongoing public health announcements and handouts by doctors and nurses and attempts at patient education you find yourself negotiating with strong willed patients who want a “Z Pack” or some other antibiotic which they do not need.  “I know my body,” they argue.  “My northern or previous physician knew to always give me an antibiotic, why won’t you?”

The answer is quite simple. They do not work to shorten the course, intensity or duration of your illness. They do in fact put you at risk of developing complications of antibiotic use. When your infection requires the use of antibiotics to restore health, it is worth taking these risks. When you do not need the medication it definitely is not. This was confirmed by an article and research presented by E Erik Dubberke, MD of Washington University School of Medicine in Saint Louis, Missouri commenting on Medicare Data about the death rate associated with antibiotic related colitis infections due to Clostridia Difficile.  Bacteria normally reside in our large intestine and promote health and digestion.  When we prescribe an antibiotic it kills off the healthy and beneficial bacteria as well as the infection related bacteria. This destruction of healthy bacteria creates an environment conducive to “opportunistic “bacteria normally suppressed by the normal flora to invade and take over your gut. The resulting fever, cramping, diarrhea with blood occurs as the intestine become inflamed with colitis. One of the common opportunistic pathogens is Clostridia Difficile.

Dr. Dubberke looked at Medicare data and compared 175,000 patients older than 65 years of age and diagnosed with Clostridia difficile infection and compared them to 1.45 million control patients. He found that those with clostridia difficile infection had a 44% increased risk of death. When comparing admissions to nursing homes for treatment there was an 89% increased risk due to antibiotic related colitis care.

Antibiotics are wonderful when appropriate. They will always carry a risk of a side effect, adverse reaction or complication which is a risk worth taking in the correct setting.  It is clearly not worth the risk when your doctor tells you that it will not work.

How Much of Yourself Can You Give to Others?

I have been practicing general internal medicine for over 35 years in the same community. I have many patients who started with me in 1979 and are now in their late eighties to early nineties.  Predictably and sadly they are failing.  Not a week goes by without one or two of them moving from general medical care to palliative care, very often with the involvement of Hospice for end of life care.   Medicare may now compensate for discussion of end of life issues but anyone practicing general internal medicine or family practice has been discussing end of life issues appropriately for years with no compensation. It just comes with the territory.

Most of us still practicing primary care thrive on being able to improve our patient’s quality of life and our major compensation can be hearing about their interactions and social engagements with family and friends.  It is an accomplishment to see you’re 90 year old with multisystem disease for years, dance at her great grandchild’s wedding.  No one who cares for patients longitudinally for years is that dispassionate that they do not give up a piece of their heart and soul each time they lose a patient or have one take a turn for the worse.   When I lose a patient, if time permits, I will attend the funeral or family grieving gathering during the mourning period.  Everyone gets a personal hand written letter. Completion of the circle of life and then moving on is part of the process.

I think physicians’ families take the brunt of this caring and I am sure mine does. As much as you want to have time and patience and sympathy and empathy for your loved ones, the work truly drains your tank and reserve. When you answer the questions of the elderly and their families over and over, often the same questions, it drains you.  Unfortunately, I believe my elderly failing mother is cheated the most by this process. Last weekend when making my weekly visit she was complaining again about the same things, asking the same questions that have repeatedly and compassionately been addressed by my brother and I. My wife interjected that I sounded angry and annoyed. I was. I told her that unfortunately all the compassion and understanding in me had been drained already today and I needed time to recharge.

I saw the widow of a patient who expired last month in his nineties. I had offered to make home visits and they were declined several times by the patient and his spouse. His last week of life he asked to receive Hospice care and they assumed his care.  I called the surviving spouse and wrote what I considered a personal letter of condolence.  His wife told me she was disappointed in me for not coming up to see him one last time. I apologized for not meeting their needs but wondered inwardly, how much can I give and still have something left for myself and my loved ones?

Changes Coming to Medicare Soon

CMS (Center for Medicare Services) is determined to eliminate fee for service medicine. Fee for service medicine is the system where patients see a physician or “provider” for a visit or service and the “physician or provider” bills the patient or Medicare for each service provided.  CMS argues that “providers” are seeing too much volume and providing too many services thus driving up the cost of health care and the percentage of the Gross National Product that healthcare consumes.  To contain costs they have come up with the public relations mantra of the “Triple Aim.”  The triple aim includes improving the global health of the US population while improving quality and reducing overall costs.  The true emphasis is on reducing overall costs!

To reach their goals, CMS is changing the way it pays for health care and services. By 2019, less than three years from now, CMS hopes to pay one flat fee per beneficiary to large health care organizations ( think HMOs) thus fixing their costs. That large organization will then be responsible for providing total care to a local population.   Hospitals and large health care systems have been purchasing physician practices and employing the doctors in organizations known as Accountable Care Organizations (ACO’s). These health systems believe that by employing the doctors they will control their ordering and spending habits and reduce costs to the overall system. They hope to drive an aging private community physician population into early retirement or at least to stop coming to the hospitals to care for their own patients. They still want these patients to come to their hospital for care but want their employed physicians to provide the care.

If you look around the community you will notice that the major hematologic and oncology groups are now owned by Boca Raton Regional Hospital, as is the major surgical group, several cardiology groups and a host of internists and family practitioners.  The hospital has additionally partnered with its contracted emergency room physicians to open numerous walk in clinics in young population centers to capture that business. At the same time that our local regional hospital is purchasing practices and discouraging local private physicians from continuing to practice, they have introduced a residency training program in internal medicine and surgery. By the fall of 2017 we can expect 100 internal medicine physicians and up to 45 surgical physicians fresh out of medical school and beginning their training, to be serving as a cheap physician labor force for Boca Regional Hospital.  The hope is that ultimately, the Charles Schmidt College of Medicine at FAU will attract and develop a clinical faculty worthy of a university and academic medical center that will enhance medical care in our area but until then we will always wonder, as anesthesia puts us to sleep, who actually is performing our surgical procedures?   Additionally one wonders if you become ill with a serious illness, will you be permitted and covered to see the best physician at the best institution for your problem or will you be required to stay in a narrow network of local providers contracted with the local health entity?

If physicians choose not to join a large health system organization as an employee they will be required to be part of a merit based payment system.  Government administrators, employers and private insurers are certain they can define and quantitate “quality care.”  It is unclear whether there is any meaningful evidence of what “quality care” really is.   Quality care will include parameters like patient satisfaction ( if you are not given an antibiotic for your viral illness or a narcotic pain medicine for your injury appropriately based on the illness or injury will the provider be given a low patient satisfaction grade?), did you counsel an obese patient to lose weight?  Did you counsel a tobacco smoker to stop?  Did you intervene to control a patient’s blood pressure?  All the data entry will require the physician to spend time in front of the computer screen checking more boxes and less time in face-to-face patient care.  Computers will need to communicate with each other from the office to the hospital to the lab etc. but it is unclear who will pay for this? At the end of each year the doctors will be required to send all their patient care data electronically to CMS for review.

Many physicians will choose to just leave or “opt out” of the Medicare system. They will contract privately with patients and be able to order tests and studies at approved institutions but they will not be reimbursed by Medicare for their services nor will the patient be reimbursed by Medicare for the cost of those doctors’ visits and services.  In most areas of the country where the population is not overwhelmingly composed of senior citizens 65 years of age or older, doctors have stopped seeing Medicare patients for just this reason. This may become the norm rather than the exception in South Florida as well.

For the moment my concierge practice is not changing anything. We continue to participate in all the CMS quality programs such as Meaningful Use and PQRS , vaccine registry and Eforcse (a controlled substance prescribing data base) despite the cost and time involved just to leave our future options open. I remain committed to giving my patients longer quality visits and following them where possible into the hospital when they need hospital services. As patients and citizens it is urgent that you become familiar with what CMS and the Federal Government are doing with your taxes and health care options and hold them accountable to your wishes!  If you have questions about this give me a call or set up a special time to discuss this face-to face.