Quality versus quantity

My colleagues are having this perennial discussion of how to fix our broken system, and one notion that comes up is to see more people in less time, i.e. to move faster. I notice that it’s often males who favour speed, and females who favour depth of assessment.

Regardless, we have a problem in our emergency department, as do most emergency departments in Canada – waiting times. This is the same problem as the wait to see any other specialist, only here we are talking about minutes or hours, as opposed to weeks to months. But it’s still the same problem.

The ideal of medicine is one patient at a time, in depth and with patience. When we are taught how to examine a patient, or how to interview them, we are taught “get good, then get fast.” So it may take a medical student an hour and a half to do a patient assessment. A resident or junior doctor may take an hour. A senior doctor may take a half an hour.

…or in the world of the emergency department, these times may be shrunk to five minutes. Currently, a clinic where I work has proposed that doctors should see six to eight patients an hour. That’s eight to ten minutes per patient. I know a few doctors who are comfortable working at that speed, but many more who would not choose to go that fast.

The emergency department where I work has proposed a rate of two to three patients per hour, or twenty to thirty minutes per patient. This includes intital assessment, ordering and reviewing tests, speaking to consultants, providing treatments, and planning for discharge or admission to hospital.

A friend I know who works as a family doctor says that it’s possible to make a decent living (i.e. save for retirement and kids’ college education) as long as he sees forty patients a day – one patient every twelve minutes for eight hours straight.

My record for longest assessment was nine hours – starting with a patient being interviewed in my office, having a seizure, getting transported to the emergency department where I treated his seizure, to more tests, to discovering that he felt the seizures were from a curse, to his cousin bringing some holy water in from a church, and finally to discovering that holy water seemed to stop his seizures. There were many breaks during those nine hours, where I left him to rest and saw other patients. It was a very satisfying case, but there were probably a lot of other patients who had to wait longer meanwhile.

Patients are spilling out of the rooms and into the hallways!

This is a hot topic in number medicine – overcrowding. Too many patients for too few rooms. Too few nurses, too few doctors. Too few operating rooms. Shortage. How long is the waiting list to see the doctor? Or the specialist?

In Canada, the federal government set up a national health care system about fifty years ago. The idea was that it would be paid for through taxes, so that rich and poor could all get health care. Certain items were key, such as free hospital care, and free doctor visits. Other items were hazy, such as free physiotherapy or free psychotherapy. But in general, getting seen in a Canadian hospital is free – food, accommodation, medications, tests, surgeries, and now wifi.

This has an interesting effect on homeless people, who sometimes come to the hospital to obtain shelter. They don’t add significantly to the crowding.

Who decided how many doctors and nurses we need? The problem is apparently that the demand for health care is limitless – the more that it is available, the more that people will use it. So the government caps the number of hospitals, operating rooms etc etc.

Another argument is that a doctor’s degree is a “license to print money,” and that doctors will drum up business if they can – doing needless surgeries, for example.

So we limit the size of the health care system.

Then the hallway problem starts to show up. The problem is that there isn’t enough money for more doctors, nurses, and rooms to see patients, or so we’re told. Those of us who are forced to see people in hallways, where there is no privacy, have to interview and examine patients differently than we would otherwise. Our overall sense is that we do a worse job of assessing people when they are in the hallway. Maybe this winds up costing the system more money, because these people get more complications.

On the other hand, the lack of privacy may be a benefit, since the patient is being seen more frequently than if they were in a room. Maybe being in a hallway results in fewer complications.

Most people, but not all, prefer a little privacy when they are sick. Perhaps hospital emergency rooms will have to start giving the option of the semi-private cubicle, the same way that airlines have started to give the option of the seat with slightly more legroom.

Perhaps in a perfect world, our hospitals would be huge, with lots of doctors and nurses, operating rooms, cat scanners and so on. There would be no waiting to be seen, no waiting lists – if it was decided that you needed a hip replacement, you’d get it done tomorrow. There are private clinics in the United States that work this way. They are expensive.

Humans are the number two

Two eyes, two ears, two nostrils, two nipples … (one belly button).

We’re not alone in this – for some reason, most animals have bilateral symmetry – where there is like a mirror image cutting through, creating an identical left and right side.

On we can go – two arms, two legs, two kidneys, two lungs … (one liver).

One incredible variation to this scheme arises when Siamese or conjoined twins are born – instead of a being who is half left and half right, a Siamese twin may have two lefts and two rights. But such people are amazingly rare – I have yet to meet one or hear of one being born in the cities where I work.

So far, so good – seems obvious to say that animals are bilaterally symmetrical — except that they aren’t all made this way. Starfish are a good example, while Fiddler crabs are a more subtle example.

Humans sometimes made a big deal out of being left-handed, especially in sports. Handedness appears to break the rules about symmetry a little – if we were truly symmetrical, we should all be equally good with our left and right hands. And yet here we are, a little like Fiddler crabs, in the sense that most of us are right-handed.

And no one has a terrific explanation for why this is so. After all, the uterus, where we are all built, is a symmetrical organ – not like it has more space on the right side for the fetus to practice its handwriting or pitching skills before birth. The brain, which controls our hands, is symmetrical when we are born. So we’ll have to chalk up handedness to a mystery.

Then there is the liver and the spleen. For almost everyone, the liver is tucked under the right ribcage, and the spleen under the left. The two organs are very similar to each other, but the liver is much, much larger than the spleen. Also, the spleen is regarded as much less important to life than the liver – some people get their spleens removed and live healthy lives afterward. Can’t take out your liver and avoid dying soon after.

So humans turn out to be mostly the number two. And why that is the case is a mystery.

“Can I film while you do my stitches?”

Sometimes I feel like there’s no privacy any more…

“It’s your hand, so go ahead and film. I’d appreciate it if you didn’t film my face, and be sure not to film anyone else who’s here.”

There we go – maybe my stitching jobs are on YouTube now. I haven’t checked.

I did have the experience of being written about many years ago – by a doctor-writer who had taken over a clinic after I’d left. A patient had complained about how I had cared for her, and now he had to decipher what the basis of the complaint was, and see whether he could “fix” things for the patient.

One of the parts of his story that stood out for me was his frustration that my medical note-taking on the patient was so brief – at times limited to the words “pregnancy counseling.”

He wrote the story using a pseudonym, and never named me, so it’s not likely that anyone involved would recognize me from that tale. Nonetheless, it was a weird sensation to be written about “without consent,” as he never asked me if it was ok if he wrote about me.

That weird feeling lingers on, as I step into the world of telling true stories – how people might feel for it to be publicly known that they got stitches.

Telling stories and keeping confidences

The idea of writing and sharing my experiences as a doctor has lived inside me since I first started working. I always liked reading fiction, but some of the stories that I heard from patients went so far beyond anything I’d ever read. Surely reporting these tales would make for entertaining reading!

All the way along though, was a sense that maybe some stories shouldn’t be shared. That they should be kept private.

Part of the reason was that some stories were secret. What if a secret story got heard by the wrong person? It’s fine if someone half a world away hears about a grandson’s drinking problem, but what if that grandson’s employer reads the story?

For the first four years of practice, I worked in small communities of a few hundred people. If I had written any of their secret stories into a public setting, my career would likely have been short. So I kept those stories locked away in my brain. Some of them made it into the medical chart, and many did not.

Later, when I began working for hospitals and large clinics, there was a new obstacle to telling stories: the hospitals did not want anything made public except via the public relations representative.

On this site, I have begun to tell stories where the main character has died. One story comes from a member of my family – I don’t know how she would feel about my sharing her tale. A second story comes from my neighbor, and she has given permission for me to share her husband’s story so that people can learn from it. In the case of Henry, I have told a story which is eighteen years old, and which was very public – in the sense that everyone in the community knew that he smoked and drank. Possibly, some people did not know that he also took medications for anxiety. My hope is that this information will harm no one, but I cannot be sure.

An ounce of prevention is worth a pound of cure

When I began practice, it was as a family doctor, seeing people in the office. I had been trained to practice “preventive medicine,” and I thought my job would be both easy and valuable: get people to stop smoking, drinking, abusing narcotics. Get them to exercise more. Immunize older people against the flu. See to it that women got regular pap tests. From my perspective, it was better to get a person away from tobacco than to treat them after they had a heart attack or lung cancer from decades of smoking.

Made perfect sense. Why was it so hard to succeed with this plan? Where smoking was concerned, I tried many different approaches, but made no progress. I tried to understand why people smoked, how it made them feel, the economics of it, brand loyalty. I studied documents from tobacco companies to see how they kept their customers. And tried to reverse engineer this into an approach to quitting. I prescribed an antidepressant that was reported to double the likelihood of a person quitting smoking. Tried to understand sources of my patients’ stress.

I made little progress, but soldiered on, because one ex-smoker was potentially one less heart attack or lung cancer case, twenty years later.

Henry was addicted to anti-anxiety medications. He was in his mid-sixties, smoked a lot and drank a lot. He had a wonderful sense of humour. He was the only person that I persuaded to stop anti-anxiety meds. Then I noticed that he lost his sense of humour, and my secretary observed how unhappy he seemed. I relented on my pressure for him not to take the addictive medications, and soon after he was back to his cheerful self. Still smoking and drinking. Soon after, he was diagnosed with lung cancer, and died at the age of sixty-eight. His funeral was one of the most beautiful I have attended. I didn’t know it, but Henry was a legend on the party scene, and the live musicians who played a jig in the church almost seemed to be saying “Wahoo! Henry here – don’t be glum because I’m partying up here in the afterlife!”

After two years, I moved away from that marvelous isolated community by the ocean, and from many remarkable people. Got back to the big city and started working in hospital emergency departments. I still talk to people about stopping smoking, only now it’s more about talking about fentanyl and crystal meth and how short people’s lives may be if they don’t watch themselves. I can only hope that some of my patients live long enough to get lung cancer.