Sometimes, waiting should be on the medical menu by Ruben J. Nazario, MD
Published in the April 2012 issue of Today's Hospitalist
THE NEW YORK TIMES RECENTLY RAN a fascinating article about procrastinating. In it, experts including productivity consultants and psychologistsópeople who obviously have too much time on their handsórail against procrastination, citing its incredible hidden costs to business. They also revile procrastinators as pathological perfectionists who put everything off until later for fear of being judged too harshly.
I've been thinking about this article ever since, and I've finally decided to write a few words on the matter. Please don't judge me too harshly.
Procrastination has certain benefits, particularly in the hospital. But
Medicine is not for the risk-averse. Medicine is for the gambler in you.
patience is a virtue lost in those learning the ropes of inpatient units. The patients are in the hospital to get better, we are trained to think, and we therefore must always be doing something to make patients better.
But as I remind my residents every week: Sometimes, we must sit on our hands and wait.
Waiting: not an option?
I've been re-reading that wonderful ode to medicine, "The House of God." For those of you not familiar with the book, stop procrastinating and read it.
Samuel Shem, the pen name of psychiatrist Stephen Bergman, MD, wrote the book in the 1970s as a parody of our health system and the training we go through to become doctors. This was before work-hour restrictions and other policies that aim to make life at teaching hospitals better for trainees and, the thinking goes, for patients.
In "The House of God," residents truly reside in the hospital where raw human emotions clash with the daily pain of taking care of sick patients who, despite our best efforts, get better. "Gomers," the term Shem uses to describe the demented elderly of the hospital, "never die." This is just one of the many axioms of the Fat Man, the wise and apparently phlegmatic senior resident who helps the new interns navigate the tumultuous waters of the House of God (apparently modeled on what was then Boston's Beth Israel Hospital) by recommending that they not do anything to their patients.
I don't see this behavior in my daily hospital life. On the contrary, technology has allowed us to change the way we practice medicine, and waiting is no longer an option.
Too much care
Patients know this. That's why they clutter our emergency rooms and hang around for hours thinking that, at the end of that long wait, they'll be handed a magical piece of paper that will instantly alleviate all their symptoms. If you tell someone that "you have to wait a few days for the illness to go away," they look disappointed.
Advising patients to go home, drink orange juice and take an aspirin is no longer an option. They have to get better NOW. Waiting for an illness to go away on its own is like waiting for Godot: an exercise in futility. You are a procrastinator, doctor! Heal me now!
But waiting is sometimes what's on the menu: a tincture of time and a good night's sleep. Every day, new studies show that we do too much. Antibiotics don't do anything for common illnesses like the cold, ear infections or sinusitis. Experts have found that PSA testing delivers flawed results, enticing doctors to do more biopsies, sometimes to patients' detriment.
A survey published in the Sept. 26, 2011, Annals of Internal Medicine revealed that 42% of primary care physicians thought their patients were receiving too much care. The most commonly cited causes for this excess were fear of malpractice suits, clinical performance measures and inadequate time spent with patients. The physicians also noted that financial incentives tend to cause "aggressive care," and 62% of them thought that subspecialists would order fewer diagnostic tests if those tests did not generate as much revenue.
This is probably why primary care doctors make less money than specialists. Maybe PCPs see patients more often and can therefore wait, while specialists see the same patient only sparingly, so feel the pressure to manage more aggressively. Or they may be more concerned about lawsuits because they then become the authority on the case that did not test for a specific condition.
So what's too much or too little care? In the hospital, ordering tests is where things can get a bit out of hand. Here are some examples of too much care: repeating tests; ordering tests for weird, far-flung and exotic viruses; or taking a shotgun approach to lab work that has low yield or no relevance to the management of a particular patient.
Again, I remind my residents every week: Just because you can test for it does not mean you should. "But this is an academic institution! It's within our educational boundaries to know!" Perhaps. But we should also learn to be stewards of our health care system, and that includes minding the bottom line. Just because you can order a Big Mac every day doesn't mean you do, right?
Procrastination, self-restraint, slowing downóthese are worthy ways to practice medicine. But this is hard to do in the hospital. Why wait when we can give intravenous fluids, antiemetics, antipyretics and antibiotics? We control metabolism with drips and pills, we banish pain and infections with injections, we can even make your heart stop for a few seconds and no one makes a big deal out of it.
We can take out your putrid organs and put others in that are brand new (or slightly used). We can go into your brain, map out the location of your emotions, and biochemically alter those neurotransmitters to make you happy, or at least make you feel that the pain in your head is not that important. Why wait?
In medicine, uncertainty has as much to do with the healing process as the medicines we prescribe. And the beauty of uncertainty is that it works in numbers. Medicine is not for the risk-averse. They are the ones who order all the tests and all the procedures.
Medicine is for the gambler in you. Yes, I know, I've heard it before, "You are gambling with someone else's life!" True. But if the numbers are in your favor, then it's not a gamble. It's an evidence-based decision.
Clearly, some patients need intensive care, heroic measures or prompt interventions, and the immediate practice of medicine has saved countless lives. But when patients are stable, on their death bed or have just a cold, you have to sit back and wait. That's our challenge as both the educators of future doctors and of the public at large.
Ruben J. Nazario, MD, is a pediatric hospitalist at Inova Fairfax Hospital for Children in Falls Church, Va. Check out Dr. Nazario's blog and others on the Today's Hospitalist Web site at www.todayshospitalist.com.