Dr John Mandrola practices cardiac electrophysiology in Louisville, KY. He finished training at Indiana University in 1996. His practice encompasses catheter ablation, including an eight-year experience with AF ablation, device implantation, and consultative EP. Outside of the EP lab, Dr Mandrola's two hobbies include competitive cycling and writing. He has maintained a medical, fitness, and cycling blog, Dr John M, for the past two years.
Trials and Fibrillations with Dr John Mandrola
View all posts »Electrophysiologists: Have a heart--step forward from the bystanders
Jan 14, 2013 08:51 EST-
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When two dermatologists wrote in the New England Journal of Medicine that in-hospital care has grown fragmented and bloated, they sounded a pertinent message for all doctors, especially specialists.
The issue of the piece was that the bystander effect has grown more prevalent in healthcare, especially with hospital care. The bystander effect, otherwise known as the Genovese syndrome, refers to the phenomenon in which the more the bystanders, the less likely it is that someone will help. It has to do with diffusion of responsibility.
The dermatologists described a complicated case they shared with 40 other doctors over 11 days. If you have been (or have had a loved one) in the hospital, you may have recognized some of the things they described. Groups of doctors met outside the patient room and talked with themselves but not to other doctors or family.
It happens every day in most big hospitals. ICU docs work on the vent; infectious-disease docs pour over culture results; blood doctors look at the blood parameters; kidney doctors adjust diuretics; and heart doctors say the patient needs more tests. Invariably, electrophysiologists get called when the patient's overwhelming inflammation causes a dysrhythmia.
I encounter this often. I'm asked to see an older patient with, say, atrial flutter or ventricular tachycardia. They have been in the hospital for days. The house of cards has begun to crumble. The patient begins to look a little like Humpty-Dumpty. Yes, they may have atrial flutter—an easy ablation on an outpatient without too many other issues. But in an older patient who lies in diapers and eats honey-thickened liquids? Not so much. There's a bigger story to tell.
I walk in the room, yet another doctor in a white coat, and I can feel the stares from fatigued family members. Not words, just their faces beg me to tell them something useful.
"Is he Mom's doctor?" The faces ask.
I saw this phenomenon first hand when my mom was hospitalized just before she died. There were many doctors who each kindly dealt with their specific issue. We, and mom, were desperate for actionable information on the big picture. We heard about biopsies, lung function, platelet counts, kidney parameters, and the like, but little about the primary disease, cancer. What the hell we were going to do about the cancer?
Finally, the first hospitalist, the one that admitted mom a week ago, came back on duty. He was wonderful. He asked my mom what she thought was going on. He spoke without specifics or medical jargon. With compassion, he told us the simple truth: there was no cure; chemotherapy or radiation would only increase the suffering; and we should talk to the hospice and palliative-care team. We should get home. (Why didn't the cancer doctor tell us this?) I could have hugged that guy. I almost did—but I am a cardiologist.
In the old days, when I started clinical practice, patients admitted to the hospital had a quarterback. They had their primary-care doctor. The primary doctor knew the patient, but just as important, he or she also knew the consultants.
That's not the case anymore. Now, only a scant few primary-care doctors come to the hospital. The precarious patient, who a few days ago was playing cards after family dinner, is now cared for by a team of strangers.
It's where we are going. Three factors come to mind: First, residents are now trained in shifts. Born from concern over fatigue, young doctors have been raised in a milieu of fragmented nonownership care. They own their 12 hours, but not the patient. Second, reform measures have fostered doctor employment models. We now work for a corporate entity, not ourselves. As pawns, we feel less empowered. We consult company doctors. Third, generational change has come. Fewer doctors hang all their self-esteem on the doctoring peg. Father doctors have shows to go to; moms work half time because, well, they are moms. This is the new norm. It's what you get when you pay doctors less and force them to work in shifts. These are not complaints; these are facts.
I don't want this to come off as a rant. I want it to tell the truth. Let's get something positive from the conversation. So we know care is more fragmented. We know doctors are working shifts, and though they care deeply about doctoring, they are going to the recital on time. All this while medical care has grown more specialized and thus more dependent on focused experts.
But still, we must get to a new equilibrium. Doctors must be trained to see the big picture. Someone has to step up—like my mom's hospitalist—and confront the obvious. Someone must be the quarterback. For specialists, like electrophysiologists, it's okay to take over and speak the truth. If the patient is so sick that a defibrillator or ablation won't help them, then that's something that ought to be said—to the team and to the patient and family. Yes, it is risky; on occasion, saying such has landed me in a family meeting, where goals of care are discussed. That's harder than any procedure.
Hand washing, checklists, time-outs, on-the-john training, and name alerts are all good things. They have improved care. But this is the low-hanging fruit.
Truly better and more compassionate care will come with improved teamwork and the ability to see and confront the big picture. The authors of the NEJM piece cite a study that suggests doctors talk more if they are friendly with each other. What that emphasizes to me is the human aspect of medicine.
Measures to improve quality must not lose sight that it is humans caring for humans. We must look away from the white screen, take a deep breath, make eye contact, listen, and then speak the compassionate truth.
Some bystander has to step from the crowd. It might as well be the doctor caring for that important muscle in the chest.
JMM
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