Sunday, June 1, 2014

Notes From the Wrong End of a Stethoscope

Published in the Sun June 1, 2014

I have recently accompanied my father, who is 84, on some of his medical excursions, which has been an enlightening experience, and not in a particularly good way.  As a former practitioner of medicine, I am used to being on the other end of the stethoscope; the end with all the power and prestige.  Being the patient, or even the patient’s family member, is a different kettle of fish.

Here are some things I have noticed about the medical profession when viewed from the supine position, and I would be willing to bet that I am not the only person with these experiences.  First, old people can still speak regular, adult English.  A medical assistant interviewed my dad in a high-pitched, patronizing voice “Are we taking our medicines?“ and “How is our blood pressure today?”  When she got to “Are we having trouble walking?” my dad, who started several businesses and has multiple patents, turned to me and asked sarcastically, “Does she have trouble walking also?”  Save the baby talk for patients under four years old.

Another puzzling thing happens if a patient or family member questions a recommendation for yet another invasive test or increase in medication.  The doctor’s eyes narrow suspiciously and you can almost see a little text box over his (or her) head flashing the alarm “Noncompliant patient-Beware!”  You might think a little caution would be in order, since medical errors and complications are the third leading cause of death in the US, responsible for somewhere between 100,000 and 400,000 premature departures annually.  Doctors and hospitals are almost as deadly as cancer and heart disease.  Remember that old saying, “He was at death’s door and the doctor pulled him through.”  There is wisdom in those old sayings.  One of the first things I learned in medical school was the adage, “Primum non nocere.”  First, do no harm.  It was a solemn reminder that every medication has side effects and any procedure can go wrong.  Another saying I learned in medical school, and a personal favorite of my dad’s, is “All bleeding stops eventually.”

At one of my dad’s appointments with a cardiologist, the doctor suggested another coronary arteriogram with possible stents.  I asked, because I did not know the answer, if placing another stent in an artery that had previously been both bypassed and stented could reasonably be expected to provide benefit.  He said he couldn’t be sure unless he looked, but hastened to add that we could also just wait and see how Dad would do on his medications.  Not discussed in our conversation, because cost is almost never discussed, was that an angiogram would cost at least $20,000.  For $20,000 it seems like there should be some reasonable expectation of benefit, wouldn’t you think?

The subject of cost poses the most difficult ethical question in medicine today.  How much intervention is appropriate at the end of life?  Patients who are placed on hospice or palliative care as they approach death spend many thousands of dollars less than those who continue medical therapy.  Interestingly, the hospice patients also live longer.  Patients with heart failure, like my dad, live almost three months longer on hospice than they do if they continue aggressive treatment.  This fact is often used to extol the virtues of hospice care, but I think more likely it illustrates the hazard of futile interventions in the intensive care unit.  More hospital humor – The risk of dying in the ICU increases exponentially with the number of specialists required.  But here is the real good news:  proactive discussions (and written instructions) between you and your physician about how you want to spend the last few months of your life increase your chances for a pain-free, dignified death in the company of your family and friends.

My dad likes to say that he has already lived as long as most people can expect to live, so he is getting ready for his next assignment.  Whenever he hears the siren of an ambulance he grins and says, “There goes another meat wagon without me in it.”

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