Sunday, April 20, 2014

A Sad Tale in a Teaching Hospital

My father's friend was Sy Axelrod. Sy was a doctor like my Dad. Their third doctor friend was George Silver, and all three were Lefties from Philadelphia who trained in the 30's and 40's when the most basic ideologies had yet to be settled. Sy established the University of Michigan School of Public Health and the field they called “medical care,” to distinguish it from things like sanitation and epidemiology. “Medical care” was about the organization of medical care services. Most of the Medical Careniks wanted socialization of medical care, but they never got that far. As far as they could get was prepaid care, which became HMOs, which entailed large organizations instead of small offices.

Sy had a bracelet he wore, which said, “In case of illness, take me to the nearest teaching hospital.” That was the best way he thought one could deal with the variation of health care quality one finds in the field. Or, as my father used to say, “Every family needs at least one doctor in each generation, to protect them from all the bad care out there.”

Sy was a good Dean; he looked out for his professors and his students. He had a sense of mission, and he realized that the products that he sent forth would be his legacy. One of his professors was Avedis Donabedian, who devoted himself to the issue of quality of care; no one had done much on this until Donabedian. I remember Sy saying, “He's got his handle on this now; he finally understands it.” It was Donabedian who distinguished three levels of quality ascertainment: structure, process, and outcome. Without the structure – like properly trained clinicians – you were unlikely to produce good medical care; without good processes – doing a strep test before you decide whether or not to treat – you were unlikely to be producing good results; but of course the ultimate value of care was in the outcome, but that was very hard to measure.

They believed that the pinnacle of excellent medical care was at the great teaching hospitals; for them, it was the University of Michigan University Hospital. They had all the structural elements necessary to produce great care. Their professors were excellent and did great research. They were intelligent people who could discuss concepts and who agreed with Donabedian's concepts of quality. The house staff were highly selected and motivated. Everything was in place at the University of Michigan.

Then Donabedian got sick. I forget what his affliction was, but he was cared for at, naturally, the University of Michigan. What he found there as a patient was a disaster. Every element of process quality that he defined was violated. Coordination? Forget it. Continuity? Non-existent. Etc. He and Sy were vexed and bemused, but it was too late in their careers to think much more about it.

My Dad, on the other hand, had left the University of Pennsylvania setting early in his career, unhappily so. He was told that there was no room there for a Jew, and he found his place elsewhere in Philadelphia, getting his revenge by living well, and getting research grants and heading a teaching program independently. He bacame a world-renowned neurosurgeon with an attitude problem. Like, he thought all the NIH grants went to friends of the reviewers, although my Dad got his share. Nonetheless, he was right, there is a problem of safety-first with peer-reviewed grants. He also got his revenge by having a CT scanner before the less-nimble University got theirs, and giving them middle of the night appointments.

One time, my Dad was brought in as visiting professor in neurosurgery at the Cleveland Clinic for a week. He came back and said, “That's where you should go if you get sick!” Their secret? “They don't have any residents!” All they did was focused on patient care; that was their proclaimed goal, not the traditional three-legged academic medicine stool of teaching, research, and (lastly) patient care. As a clinician, my Dad's opinion differed from Sy's. My Dad got his coronary bypass operation at the Episcopal Hospital where he had led the staff for years, and got his atrial ablation at the Lankenau Hospital outside Philadelphia, and his aortic valve fixed there as well. His final caretaking institution was the long term care unit right in his retirement home. No academia for my Dad.

My Dad was a sensitive and argumentative sort, and very much the neurosurgeon. Sy on the other hand, had pride in his academics. Sy thought my Dad didn't understand all the relevant points, and my Dad wasn't going to take any shit from an academic. They parted ways in acrimony. It was really a shame; the three couples, the Axelrods, the Shenkins, and the Silvers, had spent many good times together, and it just ended like that. Dad said how can you take my views so unseriously and disrespect me, and Sy said if you're going to say mean things, how can we be friends. It ended.

Now, years later and here on the West Coast, you would think the medical care issues would be different, but they're not. My wife's ex-husband Bruce, the father of my step-children and the grandfather of Lola, a very nice man who has been an attentive father and grandfather and a thoughtful ex-husband, unfortunately has esophageal cancer. After local oncologic treatment he had his surgical excision at UCSF in an eight hour procedure. I have no doubt that the surgery was excellent, but five out of ten nodes were positive for cancer, and there was local invasion. Such a disappointment.

He went home and lost weight, and then after a few weeks started retching uncontrollably. He went for care back to UCSF and got … a resident, wouldn't you know. A pompous resident. A resident who didn't see why he had to be admitted; after all, it wasn't something that needed an operation right away, I guess he thought. A resident who while he talked turned away from Sara, Bruce's daughter, who is the physician for this generation of the family. It was hard to contact the attending physicians who had operated on Bruce; they were signed out to the residents.

But Bruce was eventually admitted, after spending an interminable time in the dark interior holding area next to the ER, with curtains separating four patients, the others having to listen to Bruce's retching. After two days, on Friday no one rounded on him. Sara discovered by looking at the chart that his sodium was down to 130, too low. She tried to contact the residents who were taking care of him but was unsuccessful. Today on Sunday the sodium is down to 128 and he had not been rounded on by the time Sara finished her own rounds on her patient. Sara had the nurse on the floor page the residents three times and they finally responded that they had 40 patients to round on, had been going since 6:30 AM, and he just wasn't their highest priority. The nurses told Bruce's wife that he might be discharged today. Sara told them not to accept discharge with a sodium so low. Besides which, Bruce has a jejunal tube inserted for feeding and no one has taught his wife how to use it. And of course there is still little discussion of a diagnosis – why is he retching? There appears to be no game plan. Bruce had been scheduled to see the oncologist at UCSF to see if any further chemotherapy would be helpful, but that was the day he was admitted, and there has been no contact from that office.

American medicine is sick, clearly. The system is unarticulated. UCSF doctors are great in what they do, for the most part, but as an institution they don't take care of patients very well. My Dad had it right – we need more Cleveland Clinics. There are calls for “centers of excellence,” and they would be great. But large institutions can go off on their own tangents for their own purposes and lose track of the individual mission of medicine. Residents need to be trained, but throwing them in the pool as asking them to swim might not be the best training regimen. I could go on about academic institutions, I guess, by why do that? Just to say, my Dad probably had it right, and here we are with the same problem all these years later. I feel so bad for Bruce, and for all the other patients who have to endure the ill effects of poor organization.

Budd Shenkin

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