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March 8, 2012

Hurry up and wait

The New York Times recently ran a fascinating article about procrastinating. In it, experts including productivity consultants and psychologists—people who obviously have too much time on their hands—rail 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 thought about this article all week, and I’ve finally decided to write a few words on the matter. Please don’t judge me too harshly.

Procrastination has certain benefits. I find that time is an incredible sieve that helps one prioritize one's life, which is particularly true in the hospital. 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.

I’ve been re-reading that wonderful ode to medicine called “The House of God.” For those of you not familiar with the book, don’t procrastinate any longer, and read it.

Samuel Shem, the pen name of Dr. Stephen Bergman (a psychiatrist), 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, in spite of 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.

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. They look at you as if you are crazy—or, worse, as if you have scammed them into waiting all that time for nothing.

Advising patients to go home, drink orange juice and take an aspirin is no longer an option. They have to get better NOW, for they have to continue their busy lives; they can’t miss a day of work, they have to take their children to their activities, they must continue, they must go on. 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: 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 the PSA test is inaccurate in detecting prostate cancer, and that flawed results enticed 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 behind 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 that 62% of these primary care docs 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. (I’m being deliberately naive and giving my specialist colleagues the benefit of the doubt, not taking into consideration financial motives.) I find it amusing when someone puts him or herself on the imaginary witness stand and has the imaginary lawyer asking questions like, “So, Dr. Nazario, you told my patient that he could wait. And now he is missing half his brain. Why wait?” To which I would say, “Maybe YOU ate half his brain, you zombie! I rest my case!”

So what’s too much or too little care? I know that 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 having a shot-gun approach to lab work that has low yield or no relevance to the management of a particular patient.

Again, like 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 system, and that includes minding the bottom line. Just because you can order a Big Mac every day doesn’t mean you do, right?

Going back to my initial point (and what serpentine routes we take to make a point!), procrastination, self-restraint, slowing down, these are worthy ways to practice medicine.

This is hard to do in the hospital. Why wait when we can give intravenous fluids, antiemetics, antipyretics, antibiotics, anti-this, anti-that? We control the metabolism of the body 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. Those 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.

Yes, 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 deathbed 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.

Sometimes you just have to eat a cookie and procrastinate.
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About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is now medical director at Inovalon, a health care data analytics company, and is medical editor for Elsevier's First Consult. A pediatric hospitalist, Dr. Nazario is a veteran of both community and academic pediatric hospitalist programs. All material represents his own views and does not reflect the views of his employer.
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