What is a "Best Hospital"?

U.S. News ranked the hospitals again, and my employer came in first, for the 20th year in a row. I can't be unhappy about that!

But how should you choose a hospital anyway? I wrote about that a little while ago - it's more complicated than U.S. News makes it out to be.

Unfortunately, as a recent research article points out, the U.S. News index is based nearly entirely on reputation. Which is not a terrible thing, as I pointed out, just incomplete.

Maybe we should rank hospitals (or, at any rate, medical schools) according to a different index, say social mission? Some folks tried that, and their results are presented in the Annals of Internal Medicine (subscription required).

In that list, Hopkins, as well as NYU - where I trained for residency - are ranked rock-bottom. But the criteria used to quantify social mission has some big problems, as an accompanying editorial points out (sub. req.).

Until we have comprehensive outcome measures, it looks like we're going to have to integrate all indices according to our own individual metrics. Isn't that called reputation?

How should patients decide which hospitals are best for them?

Johns Hopkins Hospital is consistently named one of the best in the country. I can’t disagree with that; after all, I just started working there as an internist in September. Coincidentally, in the midst of the raging debate around health care reform, the past few months have seen increasing discussion of a small but crucial question: why do some of the best hospitals spend more money than others? If other hospitals named to the best-of lists consistently spend less money than my employer, shouldn’t we be emulating them instead? And how should an individual patient go about deciding which hospitals are the best for them?

Read more at KevinMD.

God, Doctor, and Patient: The Uncomfortable Hospital Triad

I would never pray with a patient at the bedside. What doctor has time to talk about God? And who knows whether a patient will find the suggestion of prayer offensive, helpful, or rapport-building? Most of us doctors, when we think about prayer at all, keep it as far from our work as possible. I am an observant Jew, yarmulke wearing and Sabbath observing, and I pray three times a day. But never would I mention to my colleagues a word about my daily spiritual practice. We are practitioners of our own esoteric art, which we like to pretend is uncontaminated by outside influence, and our white coats are not cassocks. Even when an appreciation of religion might be of some use, we make an extra effort to keep it at a distance. When patients are about to die, or when our care is serving only to prolong suffering, we delegate the hard questions to highly trained ethicists sharing our worldview. When there's nothing left but to commend a patient's soul to its maker, we murmur something about "medical futility."

Thus the small but growing scientific literature linking prayer to health is discussed by nobody in my circles. It's in the same category as "alternative" medicine (acupuncture, Chinese therapies, ayurvedic medicine, and the like) or, for that matter, most of psychology - areas worth dabbling in but never imagined by orthodox practitioners as primary to the profession. Once organic causes have been thoroughly "worked up" (through appropriate technologies and laboratory tests), then we are free to speculate about the psychological and spiritual realms, usually with a cocked eyebrow or an eye on the clock.

What would it mean for prayer to help the sick? It's a question linked to others great philosophers have plumbed and foundered on: the existence of evil, God's relationship to prayer, the necessity of any belief in God at all when one prays. One might think that the scientific literature shouldn't find the problem as difficult as the philosophers - just find an objective measure of "prayer" and "help." But objective measures of prayer are precisely what are lacking, as psychologists Kevin Masters and Glen Spielmans explained in a review published in the Journal of Behavioral Medicine in 2007: what the field needs are "experimental studies based on conceptual models that include precise operationally defined constructs [and] longitudinal investigations with proper measure of control variables." In other words, we're back to the same issues: what is prayer? And how do we tell what is the effect of prayer, and not merely the nonspecific warmth of human companionship?

God is most relevant to me at work for different reasons. I'm a medical resident in his final year whose routine usually involves others' tragedy. Religion in my practice is usually evident only as a wedge between what I want and what patients - and, more often, patients' families - want. Enveloped by a medical culture which is difficult to step outside, I often catch myself assuming with an unquestioning certainty exactly what should happen in a given case: this person over here is worth treating (from a "medical" perspective - that is, from the perspective of my guild), there is progress to be made here, and we should try to convince the patient and family of this; or, conversely, there is "nothing to treat here," and any protestations to the contrary are due to delusion, illusion, or "cultural differences," a common euphemism which includes religion. Often it happens that religious patients and their families want more care than we doctors want. This is frustrating for me as a religious person: what's the point of all the spiritualism if it only blocks lines of communication between doctor and patient?

As in the case of prayer and health, the issue of end-of-life care for religious patients (and their families) can be illuminated through empirical research where otherwise we might get lost in philosophical byways. In a recent issue of the Journal of the American Medical Association, Holly Prigerson at the Harvard Medical School Center for Palliative Care, together with her colleagues, published a rigorous study of patients who use religious faith to cope with a diagnosis of advanced cancer. Even after controlling for other variables, these patients with "positive religious coping" request and receive more intensive life-prolonging care at the end of life.

In an on-line interview, the authors declined to make recommendations to clinicians based on this conclusion. In the article, however, they observe "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment, intensive end-of-life care might represent a negative outcome for religious copers." This would certainlly justify doctors' bewilderment when dealing with religiously intransigent families. Such families are arguing their loved ones into more days in the ICU and a death entangled in wires and tubes.
Thinking it about it in another way, though - trying as hard as I can to think like the spiritual person I occasionally manage to be outside of work - a scrabbling after every scrap of life, even as it seems to slip inexorably away, is a perfectly religious path. For many religious people, sick or well, the question is not "Does prayer help?" but "How can I manage to pray?" Prayer has no point; its existence is enough. Similarly, I would not be surprised if many religious families viewed the question of "negative outcomes" as just another barrier thrown up to the achievement of transcendence. Life is life. Clinging on to it has no point; the clinging is enough. These days our art of medicine is always accompanied by debates about the evidence, what it is and how one introduces it into practice. While God and God's adherents frustrate me no end while I am trying to get work done in the hospital, I am vivified by those whose attachment to life is circumscribed by something other than evidence.

She doesn't know why she's in the hospital?

I'm still thinking about an all-too-common hospital situation: doctor and patient don't agree on the reason why the doctors put the patient in the hospital. I'm giving a revised talk about it on Wednesday to my primary care colleagues. Comments welcome!

Ill-Suited for Rapidity

Today's hospitals are all about the Rapid Response Teams.

But I was born a member of the Languid Deliberation League.

Resident work hours in the Times and the "Journal"

The Well blog at the New York Times talked about the new Institute of Medicine study, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. I'm not likely to read it, but the IOM "asserts that revisions to medical residents' workloads and duty hours are necessary" to protect patients against errors and improve the educational environment.

The comments at the Times blog are to be avoided, as most comments are. Try this New England Journal article instead for a take on the tricky balance between work hours and handoffs. The fewer hours, the more handoffs. And fewer hours, with today's sicker patients, don't mean less work.

"Intoxicado" Does Not Mean "Drunk"

Among Cubans, “intoxicado” is kind of an all encompassing word that means there’s something wrong with you because of something you ate or drank. I ate something and now I have hives or an allergic reaction to the food or I’m nauseous. On the day Willie’s intracerebellar bleed began, he had lunch at a fast food restaurant, the newly opened Wendy’s. His mother and his girlfriend’s mother assumed that the severe headache he experienced that night was related to eating a bad hamburger at Wendy’s - that Willie was “intoxicado.”

More at the Health Affairs Blog about a terrible linguistic misunderstanding. "Neither the ER doctor nor the family requested a professional medical interpreter because each side believed they were communicating adequately."

Chasidim complain about Maimonides?

Last week's issue of Zeitshrift, a Yiddish magazine from Monsey, has this cover headline in red and black:

The Truth About Maimonides Medical Center
Community leaders and dozens of former patients complain to Zeitshrift about negative treatment in the Borough Park hospital - Some leaders say that other hospitals aren't any better - What can we do to improve the situation?

Inside is a 15 (!)-page article about the hospital, its detractors, and its defenders.

Bits of work, or: Passover primary-care cleaning

Yesterday I taught a class to (better: had a discussion with) my colleagues in the Primary Care program about risk perception.

Today I gave a presentation about some ongoing research: (to what extent) do patients and the medical chart differently report the doctors' reason for their hospital admission?

You can attend the talk too!

Competent to judge: Adventures in hospital ethics

The guy with newly discovered metastatic cancer who was just told of his diagnosis - when he wanted to up and leave, that wasn't crazy of him. Nor was it necessary to call a psychiatrist to judge whether the patient was competent to leave against medical advice. Is there anything magic about psychiatrists which makes them able to judge competence? Some people like titles, and other people like subspecialties. Psychiatrists on call in the hospital become surrogate ethicists, for a reason I don't understand. Because psychiatrists are on call and ethicists are not? Or because we (doctors and everybody else) tend to confuse the legal with the ethical - and we're familiar with psychiatric judgments of mental illness?

It would be too easy - unfair, really - to say that some doctors who think patients are incompetent, or crazy, are unable to see why anyone might disagree with them. But I'll say it anyway.

The Resuscitational Imperative, II

On the other hand, there is now definitely a culture (measured by off-hand comments by residents, facial expressions assumed when discussing families who do not make the "correct" decisions, and the like) which promotes the DNR order. It is taken by some as the very goal of goal-of-care discussions. If a patient is very sick, has been so for a long time, and the prospects for recovery of functional status (meaning a significant quality of life) are minimal, we are pleased when a DNR/DNI order is obtained, and even more pleased when comfort care is decided upon.

But I also want to talk to the patients fully and frankly about what "significant quality of life" means. If the patient (or her family) wants to be kept on a ventilator indefinitely, even if there is no chance of life off the machine, that would be valid - because medical futility, like all medical decision-making, involves ethical assumptions which patients and families might not share; and because health-care costs and resultant rationing, so often in the back or front of our minds when discussing such issues, are not significantly affected by long-term ventilator support. (See this brief article in the New England Journal for a discussion of both these issues.)

My goal this rotation, when I admit patients overnight at Bellevue, is to include as part of the problem list the category Goals of Care and to discuss these with the patient. This won't happen for everybody, and maybe for nobody (it gets busy). But it's something to work towards.

The Resuscitational Imperative

It's not a technological imperative that drives the resuscitation of so many patients who (if you had asked them while they were of sound mind and not about to die) would rather not have been resuscitated, it's a philosophical imperative. Most doctors, in my admittedly limited experience, are biased towards doing something rather than nothing. Or - rather - biased toward the assumption that taking a positive action is more helpful, because more active, than doing nothing. But sometimes doing nothing is not doing nothing at all. Letting someone die can sometimes accomplish more than a breathing tube or a defibrillator ever could.

Distress and disease: inextricable

The important lesson to be drawn from studies of medical-psychiatric comorbidity is that distress and disease both produce physical symptoms. It is not productive to dichotomize symptoms as "somatogenic" and "psychogenic" because physiologic and psychological processes are involved in all symptom production and perception. "Rule out" diagnostic strategies that search for either a medical or a psychiatric cause of a physical symptom are not supported by epidemiologic findings of high rates of medical and psychiatric comorbidity.

-from Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology. Ann Intern Med 2001;134:917.

I remember last year when I started the night float rotation; the interns passed around a handout, compiled a few years ago by some previous interns who were now attendings, about how to diagnose common inpatient complaints. Anxiety languished far at the bottom of the list for diagnoses explaining chest pain. "This is a diagnosis of exclusion!!" said the handout - the implication being that no one should ever diagnose anxiety (or other psychological complaints) on the hospital floors. The cultural supposition is that chest pain is either a heart attack, or an aortic dissection - or else it's "bullshit." (No one would write this, of course . . . it's understood.)

All the regulations: whose fault are they?

Whenever I complain about the bureaucracy attendant on every decision in our residency program - squashing us like bugs - the answer comes back: "Yes, JCAHO makes things hard for us." But the Joint Commission includes corporate members: the American College of Physicians, the American Medical Association, and the American Hospital Association. If my home institution, for example, thought that the JCAHO requirements were needlessly onerous, couldn't it organize opposition together with its fellow institutions? Or are we all just being sucked into a bureaucratic vortex?

Yet another DNR
Do Not Reimburse.

A recent article in the New York Times publicized changes in Medicare subsidies. In the article’s own words, “Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move [that] could save lives and millions of dollars.” This change was widely discussed, no less so in our hospitals.

But the devil is in the details. What is a preventable error? How was the list modified, and whose idea was this in the first place? What are the implications for our daily practice?

Learn more in Clinical Correlations.

Presenting the second-year resident
Now in a magically supervisory capacity.

Said the cattle thief: it's time to take stock.

The intern is a snake devouring its own tail. The second-year resident ("R2" is the quasi-robotic nickname) is still chewing at her tail but is also keeping an eye on the tail-devouring of other snakes, with helpful comments all the while. "Open the maw a little wider! Fangs into the tail like you mean it!" And the hot sand all around, with the Georgia O'Keefe-ish carcasses. And the whistling of passing trains.

The meaning of the allegory: I still sometimes don't feel like I know what I'm doing, even with years and years - I mean, fourteen months - of medical experience under my belt. I know for a fact, more abstract than concrete and more intuitive than learned, that it is better to say "I don't know" than to invent a probably-misleading principle on the basis of limited information. But the latter is what I see people doing all the time around me, and whenever I say "I don't know," I still feel guilty and weak.

Some of this is due to lack of confidence, which will be repleted steadily until my graduation, at the end of my third year of residency. Some of this is due to epistemological uncertainty. I don't know what it means to know about medicine, and at times I'm not sure that everyone else does either.

Let me qualify: there are many models of what it means for a doctor to know something, but none of them covers all the situations that we encounter. "Evidence-based medicine" (one model) is a misnomer, because the "evidence" is population based, while much medicine is done person by person. There are many other jerry-rigged epistemologies, lizards skittering up and down the hospital hallways between the feet of housestaff. "See one, do one, teach one" - sure, but what is "seen" and "done" depend very much on how one is taught. Diagnostics is an epistemological minefield: take into account all your probabilities (Bayesian and otherwise), but you must still walk into a patient's room with at least two or three layers of information and attempted diagnoses made by other people in the hospital who have seen the patient first. Seasoned diagnosticians often cannot explain how they arrive at the correct diagnosis; on the other hand, autopsies (of a previous generation; these days they're rarely done) indicate that diagnoses are wrong about a quarter of the time.

The epistemologic dissonance par excellence is between doctor and patient. The doctor knows the patient's sick, and the patient doesn't believe this at all - or vice versa. The patient knows what's going on in her body, but the doctor needs to do another test to find out - because he says he doesn't know yet. You can say that this is because doctor and patient subscribe to different epistemologies (biomedical vs. traditional, quantitative vs. narrative, or what-have-you), or you can say that neither doctor or patient knows how they know things, or thinks about it much at all. (Meta-epistemology? You came to the right place.)

Now I'm a second-year resident, with more time to think about how I (don't) know what I (don't) know. This is precisely the time when I am supposed to start conveying my knowledge to those one step below me: the interns. (Many of whom, in terms of raw medical facts and figures, know more than I do anyway.) It's appropriate that I don't feel like I know how to do this.

Perhaps I'm thinking about this all wrong. Medicine (or, to term it more appropriately, health/sickness/wellbeing) is based not on knowledge but faith. Induction is a leap. The sun will rise tomorrow because we've seen it done so for our entire lives and heard stories about its constancy. Doctors and patients alike put themselves in the hands of their combined trust: standing at the foot of the mountain or at the door of the hospital.

Difficulty naming objects
. . . in English, maybe.

Neurology consult's note (about a Spanish-speaking patient of mine): "The patient has some difficulty naming objects. He calls eyeglass lenses 'crystal.'"
In other words, he calls eyeglass lenses cristal.

An Intern's Lexicon
Version 1.0
Descriptive only. Not prescriptive, endorsed, or reflective of these terms' actual scholarly or humanistic meanings.

A-stick (v.) to draw blood through puncturing the radial artery.

Baseline: at baseline (adj.) Describing a usual or healthy state before arrival in the hospital or before some insult or incident. "His baseline mental status is poor."

Code: 1. (v.t.) To attempt to resuscitate a patient. (n.) An attempted resuscitation. 2. (v.i.) To undergo an attempted resuscitation. 3. (v.i.) To die after an unsuccessful attempted resuscitation. 4. full code (adj.): Someone who is to be resuscitated in case of cardiopulmonary arrest. Opposite of DNR.

Cute: (adj.) Possessed of some attractive or positive attribute. Used of older patients. "That patient of mine in the step-down is so cute! He sits there with his blanket, reads the paper, and asks me how I am when I pre-round on him in the morning."

Dispo: (Short for "disposition.") (n.) Plans for discharge, or a patient's destination upon being discharge. "She's hanging out, waiting for dispo."

DNR: Short for Do Not Resuscitate.

Fail: (v.) (paradoxical reverse construction) To be unsuccessfully treated by a medication. "That gomer failed Vanc[omycin], so we put him on Imi[penem]."

Female: (n.) Woman.

Fix: (often jocular) (v.) To treat, especially acutely. "Your list is so small!" "I fixed everybody."

Gome: Short for "get out of my emergency room." Originally used in House of God, now generally used. n. An older, chronically ill, demented patient. -- Gomey (adj.)

Hang out: (v.) To stay in the hospital while no longer acutely ill. "Anything going on with Mr. Smith?" "He's just hanging out."

Ins-and-outs: Measurements of intake and output on the part of the patient.

Jeopardy: (n.) A backup system whereby certain residents are called in when others become sick or otherwise unavailable.

Male: (n.) Man.

Mental status: (n.) Cognition.

Psych issue: (n.) Psychiatric, psychological, or emotional complication. More generally, any expression of feeling.

Resp (v.) : Short for "respire." To breathe at a certain rate. "The patient is resping at 36."

With it: (adj.) Able to converse; interactive. "He was with it when he came into the hospital

Floating at night

The hospital, with all its activity and mad transformation, is subdued at night. A cover is dropped over everything.

But it is not as if everything goes to sleep. The activity is dampened but not stilled, like music heard outside a soundproofed room.

Even those events that happen in a mad rush - the resuscitation, the emergency surgery - feel slower. It is night's recognition that daytime matters. Not every shift is like every other.

Para-rabbis and PAs
"Totem pole": descriptive, not prescriptive.

MEDICINE MENSCH: What Little I Know About Medicine
By Zackary Sholem Berger
November 11, 2005

I thought I would title this month's column "What I Don't Know About Medicine," but my editors want 800 words, not an encyclopedia. What I do know about medicine should fit nicely into the space allotted.

The rotation I'm starting this week is known in hospital jargon as the sub-internship; the registrar's office calls it "advanced medicine." In this rotation the medical student plays the role of an intern, a first-year resident. He can write orders on the computer, decide on a course of treatment and prescribe medications — all with the co-signature of a supervisor, of course. The main thing is that the student manages his own list of patients. In other words, I won't be following a resident around anymore; I will be a resident.

More precisely, I'll be pretending to be a resident. That's the catch of this rotation — it's the adolescence of medical education, in which one is something more than a senior student but something less than an intern. How much like an intern will I be? If one reasons by similarity of activity (lack of sleep; independent decision-making on behalf of actual patients), I could very well call myself the intern. Could I walk into my patient's room and say, "I'm Dr. Berger, and I'll be taking care of you during your stay in the hospital?" The second half of this statement is definitely true, but the first part (with "Dr.") isn't quite. I won't have my medical degree until my graduation in May 2006, and I won't have a license to practice medicine until I finish my boards, which stretch from now (while I'm still a medical student) until the end of my residency.

On this rotation, I don't plan to introduce myself as "Doctor" (that would be quite a stretch), but I understand why some of my colleagues would. While many patients don't understand the difference between senior medical students, interns, residents, fellows and attending physicians, they come to appreciate something of the hierarchy during their hospital stay. One thing soon becomes clear to them: Medical students are at the bottom of the totem pole of health care providers. (Or almost at the bottom —more on that subject, below.) If a sub-intern walks into a patient's room and starts out by saying, "My name's Joseph Brighteyes, I'm a medical student, and I'm here to take care of you," the patient is likely to respond, "That's great, Joe, but who's going to be my doctor?"

Is qualification defined more by knowledge or by capability? This larger question comes up when talking about the thousands of people whose elbow grease makes a big hospital run as smoothly as it can. Even lower on the pole than the medical student is the physician assistant. P.A.s train for fewer years than medical students, so they often get less respect from folks in medical academia. But in every rotation where, as a medical student, I've worked together with P.A.s or P.A. students, they have seemed more on the ball than the medical students — not as over-theoretically concerned with fascinating disease entities and more knowledgeable about what might immediately help the patient. Part of the reason is that the P.A. student spends more time in her early training (most P.A.s I've met are women) familiarizing herself with the way things actually are in the uncompromisingly practical universe of the hospital or clinic. Perhaps P.A.s can't name 12 different kinds of small-vessel disease. (I'm making up that number; I certainly can't name them, either — not off the top of my head.) But such encyclopedic knowledge is sometimes transcended, or rendered irrelevant, by practical considerations. On the other hand, you don't want to miss the rare diseases when they do pop up. So both kinds of training (practical and theoretical encyclopedic) are essential, even complementary. The trick is to appreciate both kinds of thinking at the same time, even though most people find one of them more congenial than the other.

A similar divide is evident in the Jewish tradition, especially with regard to Torah study. In previous generations — and even today in some circles — memorizing vast tracts of the Talmud is a prized skill. On the other hand, if you've dipped into any of the Talmud, you know that it takes considerable exegetical ingenuity to derive laws applicable to everyday life from the rich stew of magic, folklore, intellectual speculation, casual yeshiva talk and campfire tales about the destroyed Temple. (Even the strict constructionists, those who actually bury their fingernail clippings according to the magical practice of the rabbis, still have to exercise creativity in deriving everyday religious practice from Babylonian-Jewish digression.) The two skills — encyclopedic knowledge of the Talmud and the ability to apply the Talmud to everyday religious life — are complementary, but rarely are found in the same person. Many of the greatest talmudic scholars have famously refused to adjudicate Jewish law, protesting that they could see all sides of any issue.

Today's Jewish communities rely very much on what some people call "para-rabbis" — people who aren't religious scholars but are reliable, even expert, in the details of daily practice. You might have met some of them: the guy who knows everything about building a sukkah; the woman who is obsessed with reading Torah; the member of the local synagogue who knows exactly how to help a recently bereaved family.

In other words, Jews (at least religious Jews) depend on "rabbis' assistants." In the same way, a hospital must cobble together a vast number of people who have different abilities. Some sit in offices and absorb themselves in the study of disorders affecting 10 people in the entire world, while others, down amid the gore in the E.R., can contradict those same scholars with absolute certainty if they see in front of them a practical problem they know how to solve quickly and effectively.

Bit by bit, I hope to amass both kinds of knowledge till I can be considered a doctor (a learned person, according to the word's historical meaning) in at least one of these categories. But no matter what, there always will be plenty of material for my upcoming masterwork, "What Zack Berger Doesn't Know." I look forward to doing the research.

Zackary Sholem Berger is becoming a doctor, hour by sleepless hour. Feel free to write him about it at doctor@forward.com.