Medicine is complex, and mistakes may occur despite checklists. I know everyone likes to compare medicine and surgery to the airline industry, but it's really alot different. Sure, OR time outs are an excellent idea, and gives the team time to voice any concerns. But patients aren't car engines or television sets, and aren't something a technician with a checklist can fix.

We don't mind people questioning our decisions...as long as the person knows what he/she are talking about. I encourage a team effort, and like input from nurses, respiratory therapists, physical therapists, etc...but ultimately the captain of the ship needs to make the final decision.

Perhaps I didn't state that properly. I don't mind having a lively debate about a medical intervention with medical professionals who have a different learned opinion.

If a patient or family member questions a decision the medical team has made we simply explain our rationale (if there is time--I'm not going to stop and explain to a family member why I'm giving vasopressin rather than epinephrine during a code).

If another medical professional questions a decision because they are not well trained, that's another thing. I'll give you an example: an ICU nurse once questioned why I gave Lactated Ringer's solution rather than Normal Saline to a patient who was acidemic and had a rising lactate, and subsequently changed my order without my knowledge. Her reason? Lactated ringers contains lactate and was the reason for the rise in the patients lactate (rather than the obvious hypovolemic hypoperfusion). The result? The patient received large volumes of NaCl and the patients acidemia worsened--because of something called saline induced hyperchloremic metabolic acidosis. http://medicine.ucsf.edu/education/resed/Chiefs_cover_sheets/acid_base.pdf

Again, I don't mind being questioned at all. Not sure how you took my statement as a lack of respect for patients. Actually I usually don't "dumb things down" because that seems condescending to patients. I will ensure that they understand by having them explain to me what I've just stated. If they need a simpler explanation I'm happy to draw pictures or bring out videos or whatever they need to come to well informed decision. However, in the long run I have to be the physician and cannot let a patients family dictate medical care, as they don't have the training.

Checklists can be very helpful, but aren't a panacea.

Wakehead, I would like to see the inside of your mouth as your comment, "experienced doctors are infallible", wreaks of someone who has had his/her tongue surgically implanted in his/her cheek. (At least I hope that was tongue in cheek.)

Wakehead

I'm sure most docs would agree.

Getting a younger doctor to see doesn't fly in the face of common sense at all. Established doctors are stuck in that Nixon; less care higher Ins premiums rut. Younger doctors are not bitter and angry over the little stuff like the old ones are.

I live in a different State than where my Workers Compensation claim is - trying to get an out of State provider to agree to be a provider in another State is near impossible. I had to fly to Seattle 4 times this year to see a shoulder doctor - because of the 37 orthopedic doctors I contacted in Tucson, none of them were willing to become an out of State provider - and they hate L&I (workers comp) patients. The system is so rigged it isn't funny.

My mother lived to 85 and Dad until he was 91. Aging parents need frequent medical attention quite often, mostly. In their day, doctors and other professionals were put on a pedestal and were considered, pretty much, infallible. Today, with competent knowledge available through such web sites as the Mayo Clinic, for instance, the medical 'consumer' is much more aware of the broad range of options for diagnosis and care for various injuries and illnesses.

My doctor currently (for not much longer) is from the old school even though I would predict that he keeps himself updated on current medical data. Even though, we have had considerable near heated discussions on my overall care concerning certain medical treatments. I will invest hours of searching reputable web sites on my current conditions (I'm 60) and up to date treatments. My doctor, of course, wants the final say. I am not from the old school and I can remember telling my parents that just like Plumbers, Electricians or Carpenters, Doctors come in Poor, Better and Best also. They are human and can make mistakes; tire easily; get burned out (my doctor I suspect) or plainly try to shove as many patients through the door to pay the bills as they can. I take my care personally and I do my homework. For better or for worse, the Internet and the knowledge that is confined therein will be with us for ever. Some doctors embrace it, some despise it. You are your own best advocate!

Really?????? If you are an MD making this statement, your patients lives are in jeopardy. Surely you are one of THODE MD's who pay no attention to the nursing staff. Shame on you.

Barbara,

Which one of us are you addressing?

I'm glad that MarineDoc doesn't mind having decisions questioned by "A person who knows what they're talking about" but the sad truth is that a lot of physicians (and veterinarians for the record) become hostile when a patient or guardian turns out to be someone who knows more about health care than the provider thought, and questions something that the practitioner really should be doing differently.

Additionally MarineDoc and those who think as (s)he does need to come to the understanding that even if the patient is not an experienced health care professional, indeed even if the patient is uneducated and appears to have the IQ of a houseplant, the physician still works for the patient and while they are working for the patient part of their job is to communicate with the patients about their care, answer questions, and address concerns. If they are too busy to do that then they are too busy period.

Often it is not that doctors who have been in the business for a few years can't find time to talk to the patient, but that they don't want to answer too many questions because they may be asked a question that reveals that they know less than the patient about certain developments that have come about recently with the patient's diagnosis.(God forbid those type of doctors should tell a patient,"Well let me look that up for you right now.")Then again some older physicians simply resent anyone daring to question them at all because of their egos.That is unfortunate. As an old RN I learned years ago that the best teachers that I have ever encountered or ever will are the patients who live with the medical problems that we treat.

marine doc is right on the money with his comments

People too easily like to claim that docs "don't listen" or "are greedy" because it is easier and popular to do so

The harder thing to do is actually dig for the truth

I challenge you to find any real evidence that doctors don't listen. However, there is copious evidence that there is often miscommunications between health care providers and patients.

Furthermore, the patients interests and docs interests may not line up. The thing that bothers you the most (back pain, for example--painful, but usually not fatal) may not bother your doctor the most (high cholesterol--usually asymptomatic but can be deadly)

Its not that the doc is not listening--its just his priorities are different. Namely, keeping his patient alive

I think MarineDoc is accurate in his comments. I work at a medical school in one of the practices( we have residents and med students in our practice). It is hard to agree with a patients family member if the particular family member is not well versed in medicine.

But people also need to remember that as a patient you have a right to ask for a second opinion, especially if you think you are not receiving the level of care expected!! Also you need to remember that the medical field is ALWAYS changing. there is always a new drug, or procedure or this or that. so don't go out w your pitch forks and torches and go after your dr.s!!

eric - I don't have to look any further than my own family to find evidence that many doctors don't listen. My health crashed a dozen years ago after suffering for 20 years from an undiagnosed problem. I had to fight with three doctors to even get tested for my condition. They all ran tests and said they could find nothing wrong; but, they were adamant that I did not have the problem that I was trying to get tested for. Finally, the third doctor agreed to send me for the test; but, his referral stated that he was sending me for testing to prove to me that I did not have that problem - not to rule it out (yes that was the language he used). Well, the tests came back positive and I was sent to the best specialist in the region who prescribed treatment and for 2 years refused to listen to me when I said that it wasn't working (he also disregarded my medical equipment readouts which also showed that it wasn't working). He prescribed the treatment for me - that was good enough evidence to him that it was working. I would tell the doctor something and he would tell the nurse something 5 minutes later which showed that he hadn't even listened to me. Discussion with him proved of no use - the comments on his records stated that I had "unusual ideas about my condition (which tests years later proved correct)." I have went to 8 of these specialists (had to fight with 7 of them) and only had one that actually seemed to listen. Finally after 12 years I am scheduled for another test to check for another problem that "quite commonly" occurs with my condition. If it is so common why has it taken 12 years to test me for it?

I have brought in research papers, statistics, detailed descriptions of my problems and reactions to treatments, and provided logical presentations for my conclusions based upon the evidence - all have been summarily dismissed (if they were even looked at). I have had to self-diagnose 5 major conditions and had to argue to get tested or treated for all but one of them - including base of the tongue cancer that was not "found" until it had progressed to stage IV-C. And there are still some "less obvious" conditions that I am still fighting to get tested/treated for (one of which could be the cause of my atypical presentation of a confirmed problem).

I would attribute this attitude to just a particular specialty or this region of the country had I not experienced this same attitude exhibited by many doctors covering various specialties, and were it not for family members spread across the country who have had similar problems with medical professionals.

Less experienced doctors are often more willing to test for unlikely conditions since they have not yet "learned better." My nephew's life was saved by one such doctor who suggested a possible cause of my nephew's problems in the face of three more experienced doctor's who were there saying that there was nothing unusual about his condition. He was tested and treated and told that had he been taken back home (like the experienced doctors suggested) then he would likely not have made it through the night.

I applaud MarineDoc for listening to his patients; but, in my experience such doctors are few and far between when it comes to complicated cases.

I was replying to Wakehead's post.

I don't understand your guidelines commentary.

The National Guidelines Clearing House (AHRQ) publishes 'Best Practices Standards' developed by evidence based outcomes. It takes the 'practice' out of a physicians practice.

You are using the word practice improperly. Again, one size does not fit all.

MarineDoc--and, like many physicians, you are insisting that everyone has to use words in a way that you are familiar with rather than using the words in a way that is appropriate to the context. That is, you are insisting that the world revolves around you.

The poster was using the term "practice" in a satiric way--that is, using one meaning to undercut and highlight another meaning (both of which s/he knows perfectly well). This is called "doublevoiced discourse."

And, remember that you just recently talked about not liking to be contradicted. As I am a person with a sheepskin which states that I have advanced training in rhetoric, it would be hypocritical should you contradict me. Have a great day.

If you want to sound like a folksy twit, then by all means continue using the word "practice" in this manner. Are you really such a petulant fool? Do you actually believe physicians want or need your adulation?

The context is not appropriate, as we aren't "using" patients as some sort guinea pigs. And really, it just sounds dumb.

You, and your type's only goal is to "take those doctors down a notch". Let me clue you in on something...we don't really care. There's a bit of eye-rolling, but that's about it.

After more than 60 years of dealing with physicians I have come to this personal realization:

If you are hurt in an accident, shot, break a bone, then a physician is the man you want. He is trained and ready to heal you, most of the time.

If you are ill and seeking a diagnosis, the most you are going to get from any physician is an educated guess.

We have to accept that we are not transparent, we misname and under/over report symptoms and are not the most articulate species. They do the best they can most of the time. We have to be responsible for our health and not put it all on them. After all, they are human as well. Don't be afraid to disagree with your physician if you feel they are wrong. Communicate.

And Marine Doc, you are showing your intolerance by calling people names because you don't agree. If you guys are so clever, why wasn't the terrorist service doctor in San Antonio spoted before he killed all those people. I don't think you're in a position to throw stones.

I'm not required to tolerate stupidity. And this has nothing to do with opinion. The word is being used improperly. And I'm not throwing stones. He has a choice, he doesn't have to sound like a folksy twit.

I don't think that's necessarily good advise. Having a family practitioner who knows your situation well, and takes ownership is a good thing, especially if they need to coordinate care with a number of different specialists.

One problem with the hospitalist model is continuity of care with patients who require long hospital stays. Reinventing the wheel with every change of personnel can have devastating effects.

The only thing that matters with your 'Johari Window' is the word competent. You don't have to like your physician or surgeon personally. I've had patients families get pissed off because I didn't wave hello to them in the grocery store... so the sweet/SOB thing is subjective and irrelevant in my opinion. I would hope to have a good relationship with all of my patients, but that's not always possible. And if you have 40-50 patients to see on rounds, having a chat with a long winded family member about information you've covered ad nauseum can be rather frustrating for all involved.

I know that scenario. Nearly killed me. We finally got the "new guy" together with the "competent SOB" and after some harsh words, with me siding with new guy two thirds of the time through of the discussion of my "course of care" , I was out of the hospital in four days. I hadn't been in the hospital since I had my daughter in 1979, so this was quite an experience for me. My tests finally came back clean and my illness was classified as "a freak bacterial encounter". What amazed me was that I had some input in my care. Also, I will now stay away from any "office potlucks"

MarineDoc--here's a little something that you should take to heart. There was a famous businessman who carried a little piece of paper around in his pocket--it said, "Maybe he's right."

Yes, I had a general practitioner who "knew my case" and "was invested in it." This same family practitioner was convinced that I was 1) drug-seeking, 2) hypochondriacal 3) narcissistic.

My darling general practitioner thought that, because I am not particularly thin or young or attractive, that when I talked about the fact that I was working on my dissertation, that I was lying. He thought I was making the story up because I wanted to be "on the same level as" my doctor. He also did not believe me when I said I was in pain from sitting at the computer for hours and then turning around and doing hard physical labor (I had been moving boxes of books and bookcases because my TAship was over) because I did not moan, groan, or whine--and I also did not walk cramped over and holding my back. Charming doctor approved the MRI only because it would "shut me up" and referred me to a pain specialist only to get me out of his office.

Of course, his nurses did not exactly prioritize scheduling my appointment--I was in agony for three weeks before they even scheduled it. I expect he hadn't actually approved it and was hoping that I would just quit asking. And, later, charming doctor would not approve refilling my meds because the "pain specialist" was supposed to give me something ("pain specialist" was on vacation and I wasn't going back for another three weeks). I hadn't asked pain specialist for any prescription when I had seen him because, you know, I did have some from my regular doctor at the time.

My all-knowing doctor was forced to admit that I did, in fact, have a problem ONLY when the MRI came back showing that I had a severe problem with my spine. So severe, in fact, that he doubted that the pain specialist that he had only very reluctantly referred me to was going to do me any good, and he started trying to schedule me to meet with someone who would do surgery. I said I would wait until I'd completed my full course of three shots before we should talk about surgery.

And, by the way, I do in fact have the sheepskin now.

So, my point here is that general practitioners tend to make their minds up about patients based on silly things (appearance, weight, whether or not they moan and groan) and on their silly tests (which are often wrong). They frequently lie to patients simply to get them out of the office because they don't like being told that their diagnoses are faulty.

A new doctor is seeing a patient with a fresh slate--fewer preconceptions--and in a different context. A new set of eyes, especially in the head of someone who is a specialist in treating acute castes, is frequently a good thing. Have a great day.

Funny, throughout your entire post there, you take the position of omniscience, as you seem to believe that you "know" what the physician and his staff were thinking, but somehow insist that we have the god complex. Actually having a back problem doesn't mean you aren't still a drug seeking, narcissistic, hypochondriac.

We can't go around ordering MRI's at $3-4 grand a pop for everybody who walks in with a backache. Anyway, we haven't heard your physicians point of view...and we have no way of knowing if you are embellishing your story for dramatic effect or not. And, really you seem to be intelligent enough to not generalize so egregiously.

A new physician is often the target of drug seekers. You should have heard the some of the stories I was told as an intern- really high quality stuff publishable fiction, until I looked through their records. Off topic, but drug seeking occurs quite often.

And congratulations on your doctorate, I'm sur it took much hard work and dedication. Perhaps you could tell us what it's in, so that we can offer bitter sounding anecdotes about how self-righteous and god-like whatever field you are in seem to be. Remember PhD means "piles it higher and deeper" (wow, I feel dirty even typing that in jest).

MrineDoc, I found your response to Bean@home to be insulting and therefore unnecessary.

Bean@home was telling us about something that seems to be relatively common. I experienced myself with not one but two GP's, one who had been my family doctor for decades and one who simply couldn't be bothered to really pay attention. The former may well have had a role, albeit by honest attempts to manage his multiple problems, and the latter who, if I had remained her patient for another few months, may well have killed me simply by not paying attention.

I am not a health care professional, but I now consider myself to be an educated medical consumer. I can therefore have informed discussions with my doctors about my treatment and about my management options and routines. I have to wonder, from everything that you've already said in these comments, whether or not you would allow that, whether or not you'd pay any credence whatsoever to a patient who is an educated medical consumer, or even a patient who know their own body very well and knows when something isn't quite right

If your answer to that is no, then you are doing your patients, yourself and the whole medical community a huge disservice.

You are insulted? I don't care if my patients are insulted as long as I can help them get better. Even rude, self-righteous types like Bean@Home.

Now if you are finished huffing and puffing (oh, I would have paid money if you had written "I never!!") perhaps you should re-read both of our posts. There's nothing I've written that is mere opinion or untrue. The same cannot be said for your pal Bean@Home.

Funny thing about opinions...

Very true. Most CMEs are actually advertisements. CME credit can be picked up virtually anywhere. Testing (real, formal) gets to the heart of the matter.

Are you acutely aware that pharmaceutical companies are not allowed to pay for anything, not even a novelty pen, much less catered meals and amenities? Are you acutely aware that most of these medical conventions (where CE is held) are paid for by the doctor him/herself? Are you acutely aware these docs also pay for their own staff to complete CE? Clearly you are not acutely aware of anything except the propaganda that the media has crammed down your throat the past few years. When it comes to health care and rising costs, it's very easy to jump on the anti-pharma or anti-hospital or anti-insurance bandwagon without knowing what you're talking about. Please do some research before making incorrect comments, someone out there might read and believe your opinion and take it as fact....

Thanks MmmMmmBeer.

@Beer
Not True - CEU's/CME's may be offered for free. Group Lodging for the attendee is negotiated at an un-profitable rate - the Pharma or DME sponsor then pays a higher rate to rent the hall so the resort is compensated.. Food may be provided during the conference. Transportation though is paid by the attendee.
Prior to legal/regulatory changes in 2001 golf and transportation was often paid.
I am a licensed Heathcare Worker and do know what I'm talking about.
Have another round of beer.

You must be an experienced doc...jumping to conclusions without reading the article...Distribution = "a junior doctor who randomly assigns them to one of the hospital's six medical teams." and when you get to 6,500 pts I suggest that the possibility of uneven distribution becomes much less likely. I'm thinking that most statisticians would disagree with your statement that " this type of study is typically inconclusive, misleading, and poorly formulated from the start."

Yes, this study should be examined in great detail for serious errors and repeated elsewhere, but if this study is valid and similar findings are obtained in other facilities, serious consideration must be given to address the 'experienced doc = worse outcome'; for the benefit of all parties.

This looks like it was a retrospective study (as in they did a chart review of patients admitted almost a decade ago). When you talk about "junior doctor randomly assigning..." they are talking about the admitting medical team, and it's not random. It depends on who is on call for admissions that day, since not every physician accepts patients every day. I would say that the ARTICLE about this study is misleading because we don't know the acuity, or type of the patient population or if the older physicians take sicker patients who are more likely to die or have long hospital stays. It would be wrong to compare cardiology admits to nephrology, for example.

This is sort of like "rating" cardiac surgery programs for example. Hospital A is a small community hospital in an affluent area where everyone has insurance, and perform mostly low risk, low complexity operations and has a 90% hospital survival. Hospital B is a large university based urban hospital where high risk, high complexity operations are performed, but has an 78% hospital survival. One could be mislead about the competence of the surgical staff by these numbers alone.

Actually, it's called a Prospective Meta-Analysis.

What is?

From my understanding, a PM-A is essentially several coordinated randomized controlled trials, so multiple sites can later pool their data for a meta-analysis. Not sure how that applies to what we are discussing here. Could you elaborate?

Seriously?

Not only that but 60 Minutes reported about the high incidence of cheating by foreign medical students testing to gain hospital residency in America.

VIU is completely offbase. Seriously the "1/3 of doctors who never graduated medical school"? Where do you come up with this stuff? Go have a look at how difficult it is to not only get a Full unrestricted medical license, but to become credentialed to bill.

AA...you mean from 10 years ago? Cheating on the USMLE to get a residency spot doesn't help the person complete the residency training, or pass their written and oral board exams in their specialty.

Gotta side with Marine Doc on this one.."Seriously??"

Mark - If you are a Ph.D., then I'm sure that you are familiar with meta-analysis, the Central Limit Theorem and the Law of Large Numbers. Certainly we would have a hard time constructing a a truly random assignment study (the Human Experimentation Committee you know). meta-analysis would also be tough since this is one of a very few studies we could use. However, by the Law of Large Numbers (6500 pts in the study), I suggest that the effect of the extraneous, uncontrolled variables would mitigated. Certainly, as a learned scientist, this study begs for confirmation or repudiation...

Meta-analysis of what? This was ONE retrospective study? I think you might be getting ahead of yourself there. I think it would be proper to read the actual paper and take note of the Methods before you talk about variables.

I agree with the meta analysis observation, please read "...one of the very few studies..." I do suggest that with this many subjects the probability of failure to completely randomize the patients influencing the outcomes is minimized. Ref: The ubiquitous Wiki: Law of Large Numbers and Meta-analysis.

Good dialogue here.

NEAExec - why obfuscate the point here? There is no need for meta analysis observation here and yes - I know the mean value theorem.

This issue is far simpler - is it a well constructed experiment or not? Were the statements of "random" really justified? Was there a control anywhere and how would the appropriate control be created? Does the answer follow common sense? Until that point - why worry about the numbers being valid statistically?

So, I just downloaded the study...took awhile to find it, since it's only published online in this months issue of AJM. As far as random assignment, it's not. They used the term "quasi-random". This was not a random assignment as I stated elsewhere. This is a retrospective study looking at patients admitted to the general medicine service at Montfiore. The news media picked up on this likely because it would generate silly discussion--like that other story making the rounds this month about the supposed "July effect".

Thanks for looking into that. So - if it is not truly random - then as far as I am concerned the study is complete and total @!$%#ing bull@!$%#. The junior docs could have simply been giving the attendings the more difficult cases because they felt they would be better off in their care.

The way it works in most teaching hospitals on the medicine service (it's different for surgery) is that there's an admitting team who places new patients on the service of the attending physician (or sometimes physicians). Some days are busier than others. I won't say that it's total bollocks, but I don't think it's groundbreaking research either. It certainly doesn't warrant a huge write up and discussion on a major news outlet.

I would be highly skeptical of the overall results of this study. There are many things that suggest problems with this report. Some have already been discussed here. For people who are not familiar with the journal, the American Journal of Medicine is not a top tier journal. If you had a well designed study that actually showed that the junior attendings were better than older attendings, then it would be something that would be publishable in NEJM or JAMA -much higher impact journals.

The other thing you have to consider is that this study was performed at Montefiore hospital. Montefiore hospital is a reasonable place, but it is not the most desirable hospital for attending physicians to work at. It could well be that younger physicians who were highly talented received offers to work at better institutions and hence moved on, while the less stellar ones stayed at Montefiore to become senior attendings.

(My apologies to the medical staff at Montefiore – but if you're going to publish something like this you open yourself up to this line of discussion)

So you believe that your god is an egotistical deity too concerned with your weekly tithing, that he/she doesn't understand your problems and doesn't listen to your prayers?

Hmmm. Wonder what your god thinks of your faith in him?

Medical Doctors are the most overrated profession in america, don't be surprised if they don't take it with a grain of salt...

H&M,

Please remember to utter those words as the life-flight team delivers you to a trauma center, if you ever have the misfortune of surviving a major car accident.

We won't hold it against you. Promise.

Medical Doctors are the most overrated profession in America.

What kind of drivel is that?

...they never listen to the patient or family members...

Some don't; most do. If you have a doctor who doesn't listen to you, find one who will.

The internet is full of bull.

I can understand the way you feel after those bad experiences. I have had them too.

But doctors are humans and humans are not always right.

That's exactly what I was thinking. In the OB-GYN practice that delivered my youngest child, the nurse-midwives take the lowest-risk patients, the junior OB's take the next level up, and the senior OB takes the highest-risk cases. I was a healthy 31 y.o. delivering my 3rd child naturally, so I saw one of the midwives. My friend who was a first-time mom in her 40's expecting twins saw the sr. OB. Seems like a no-brainer to do it that way...

I would tend to agree. I would also think the only way to deal with this hypotheses would be a national study of a large sample of our teaching hospitals compared with a sample of our best non-teaching hospitals. Now it is not clear if the problem exists in the system or the physician.

You have every right to change your doctor.

Because everyone knows that with lawyers those things are a given.

It's called professional courtesy or sharks swim together.

OMG! AMEN

My older doctor, who I grieved for when he retired, was not at all like you describe. He was open, honest, listened to me, discussed things with me, and if he didn't know the answer he would send me to someone he felt would. The man had no ego. He didn't order unnecessary tests, he used common sense. He was a GP and took care of everything for our entire family, from delivery of our children, vaccinations, to removal of a skin cancer. If you broke your arm he could xray and set it in his office, punture wound? He's clean it and give you a tetnus shot. Laceration, he'd do the stitches, all with no appointment, all at an amazingly low cost. And if your baby got sick on Sunday he have you come to his house, he give a shot or enough meds to make it until the drug store opened. I really really like him!

There are exceptional people like that in every profession.