With the advancement in healthcare and technology we are able to greatly extend the life expectancy of the population. For the healthcare provider that means that more elderly patients and patients with multiple chronic medical conditions are being admitted to the hospital. Some “complex” patients require a multidisciplinary approach with the involvement of multiple consultants.

As a primary attending physician for the patient you often have to deal with contradictory or even conflicting opinions from your consultants.

Sometimes, the decisions are pretty easy. For example, the patient who underwent a recent cardiac catheterization with the placement of a drug eluting coronary stent is being admitted with a massive gastrointestinal bleeding. The bleeding source is a gastric ulcer with a visible vessel. The gastroenterologist requested to stop Aspirin and Plavix that were given to the patient after the cardiac procedure. The cardiologist insists on resuming both medications as soon as possible to protect the coronary stent from clotting. Your role is to negotiate with the consultants the appropriate timeframe for resuming both medications. The timing will depend on the patient’s condition and the absence of further bleeding.

In other cases the management decisions might not be so clear-cut. A very recent encounter made me think about the contradictions in medical practice.

67 year old female presented with dizziness, nausea, left sided weakness and difficulty speaking. The clinical diagnosis of brainstem stroke was confirmed be the findings on the brain MRI. (See upper image above with the arrow indicating the site of the stroke in the right pons).

MRA (MR angiography) demonstrated a very tortuous right vertebral artery with significantly limited flow (black arrows on the bottom image above). The left vertebral artery was normal (white arrow on the same image).

The consulting neurologist suspected vertebral artery dissection as a possible cause of the vessel occlusion leading to stroke. The patient was started on anticoagulation, Heparin infusion, per the neurologist’s recommendations.

On Monday morning a different neurologist saw the patient and made completely different recommendations. According to the second neurologist, this was unlikely to be a dissection, but rather an anatomic variability in the size of the vertebral arteries. The Heparin infusion was stopped and the patient was started on Aspirin.

You are the primary attending physician and it is your responsibility to ensure that the patient gets the best treatment for her condition. The most important question to ask yourself is: if the change in medical management compromises the patient’s safety and health.

The review of the literature revealed that yes, indeed, the patients with a suspected vertebral artery dissection are often being treated with anticoagulation. Several favorable outcomes were reported in the literature. Yet, there are no randomized studies available to confirm the benefit of this therapy for the patient with the vertebral artery dissection.

Considering somewhat equivocal results of the imaging study (dissection vs. anatomical variation) and the absence of firm evidence to support the use of anticoagulation, the decision was made to change the medical management according to the rounding neurologist.

There are two questions to consider while navigating the path of contradictory medical opinions. Number one is always what would be safer for the patient – do no harm first. Number two is what would offer more benefit for the patient. The second question is often harder to answer. That is why we consult specialists in the first place.

As physicians, we all strive to practice good medicine. Good medicine means evidence based medicine in the patient’s best interests. In the ideal world this will make patients happy and satisfied. If you are getting the best treatment for your condition you should be happy, right?

In the real world, though, keeping patients or their families’ happy and practicing good medicine might not be possible at the same time. This is true for both inpatient and outpatient physicians.

A recent experience that one of my partners had to go through demonstrates the point. The patient in his mid 80’s came with a massive heart attack. He had a heart attack at home and, unfortunately, wasn’t found until later. He developed muscle breakdown that affected his kidneys. He had to be started on continuous dialysis.

Despite aggressive medical management, his condition had progressively deteriorated. The blood pressure remained low despite the high doses of medications. All major organs started to shut down. The patient was dying.

When his condition suddenly deteriorated and he developed a fatal arrhythmia, the responding physician refused to escalate care and suggested to the family that comfort care was more appropriate in his case.

The family was unable to make a decision, insisting on providing futile care. Subsequently, they became angry with the physician and complained to the hospital administration. This caused the physician emotional distress and an unnecessary headache. The refusal to provide futile care lead to a very unhappy family yet it was the right thing to do. It was the right thing for the patient.

Things might not be as dramatic in the outpatient world, yet the problem, probably, exists on an even bigger scale. Studies have shown that physicians are more likely to prescribe medications and order tests when confronted with a specific request from the patient. Often the request is granted even though it might not be the best treatment for the patient. Some studies have shown that the perception of the quality of care improves once the request is granted.

Some hospitals and clinics are even trying to improve patient satisfactions scores by adjusting the physician’s compensation and bonuses based on the patient satisfaction. Does that encourage physicians to do what the patient wants and not what the patient really needs?

A study published in the Archives of Internal Medicine demonstrated that the request for antidepressant prescription is much more likely to be granted if the patient asks for the medication directly or indirectly. In many cases these prescriptions would be considered unnecessary or even inappropriate by the current practice guidelines.

Any physician ever practicing outpatient primary care knows that patients often expect to be given antibiotics for upper respiratory symptoms, even though, viral infection is the culprit in more than 90% of cases. You might say: “What’s a big deal if the patient takes antibiotics for a few days? Even if unnecessary, it might make the patient feel like he is actually being treated.”

Now, imagine on the national level how much wasteful cost it adds to medical care. The patients are being exposed to unnecessary risks of antibiotics. Antimicrobial sensitivity will be altered in the community with emergence of drug resistant pathogens.

The bottom line is – practicing good medicine and having satisfied patients often means performing a balancing act on the part of inpatient and outpatient physicians. The silver lining, according to the study mentioned earlier, is that effective communication with the patient is shown to improve satisfaction even when the specific requests are not being granted.

Obesity is a huge healthcare problem in the United States. It has reached the proportions of an epidemic and continues to get worse. Multiple medical problems including heart disease, hypertension, diabetes, sleep apnea and cancer are closely associated with obesity. The patients with extreme obesity can reach a body weight of five, six or seven hundred pounds and even higher. Riddled with chronic medical conditions, these patients often end up in the hospital for medical care. Taking care of the extremely obese patient presents many challenges for the practicing physicians. Below are some practical considerations for how deal with extremely obese patients in the hospital and ICU.

Just moving the patient in bed or even getting the patient out if bed presents a challenge. The ceiling lifts come very handy even to just flip the patient on the side. Even those lifts have a weight limit, so now we are considering getting at least one ceiling lift with a 1000 pounds weight limit for each floor…

Obtaining a radiographical study on an obese patient could be quite difficult. Plain XR of the chest is often unreadable due to its poor quality. Obtaining more involved studies like CT scan or MRI even more challenging. Most radiology equipment has a weight limit and, sometimes, you simply cannot fit the patent into the scan because of the size limits. There were circumstances where we had to perform a diagnostic laparotomy when an acute abdomen was suspected because no useful images could be obtained.

Obese patients often have hypoventilation and sleep apnea, putting them at a higher risk for respiratory failure. Intubating an obese patient could be an absolute nightmare. Using GlideScope or even a bronchoscope might help when dealing with a difficult airway.

Venous access is often problematic as well. The amount of abdominal tissue overlying the groin often precludes the placement of a femoral central venous catheter. Using an ultrasound for the placement of an internal jugular central catheter is helpful if central line is needed. In many cases having a PICC line (percutaneously inserted central catheter) inserted could save you’re a lot of time and effort.

Once the patient is on ventilator, the excessive amount of thoracic adipose (fat) tissue leads to high ventilatory pressures. The shear weight of this tissue compressing the chest precludes the lung from adequate expansion. Thus, higher pressures are required to ventilate the patient, increasing the risk of complications. Tracheostomy often becomes the only option to wean the patient off the ventilator.

DVT (deep venous thrombosis – primarily in lower extremities) prophylaxis is at best uncertain. Many obese patients are bedridden while being in the ICU and are at increased risk for venous blood clots in their legs. The usual method of prophylaxis is the administration of a low dose blood thinner, like Lovenox or Fragmin, under the skin (SQ) of the abdomen. Considering extreme obesity, the absorption of this drug is uncertain.

Wound healing is often impaired in obese patients. This is especially true for abdominal wounds. Many patients end up having a long term VAC dressing (sponge dressing connected to a vacuum device) to keep the wound clean.

Many more practical issues arise when taking care of the extremely obese patients. The problem is not going to go away and will likely to get worse. It’s like the wife of the 700 pound patient had said once I informed her that CT scan was not an option for her husband: “I thought the whole nation is getting fatter. How come you are not prepared for this?”

Every day, while seeing patients in the Intensive Care unit, I have family meetings and conferences to discuss the patient’s condition and outline the treatment plan. In many cases the diagnosis and the treatment are straightforward. If the patient came with pneumonia, intravenous antibiotics will be given and the gradual improvement is expected.

Sometimes, the patient’s condition is far from straightforward. Yet, the family’s understanding and “buying-in” into the treatment plan are important for the patient’s recovery. Using associations and analogies might help to effectively communicate with the family. Another technique that I found useful to “get through” to the family is repetition. Sometimes, you have to repeat the same thing over and over, using different words, of course, for the information to sink in. Let’s look at an example.

An 84 year old previously healthy male presented with urinary tract infection, acute renal failure and sepsis due to an obstructing kidney stone. The patient was started on intravenous antibiotics and the nephrostomy tube was placed to decompress the obstructed kidney. On the second hospital day his condition started to improve. His blood pressure, kidney function and fever have improved. His pain was controlled with oral analgesics.

Despite his overall recovery, on the third hospital day, the patient became restless, agitated and confused. The family requested an urgent meeting with the physician to find out why this highly intelligent retired college professor is jumping out bed naked, hitting nurses and does not even recognize his own wife. The family demands to know “what is going on and what is he being given by the nurses”.

The patient likely has ICU delirium or ICU psychosis. This is a poorly understood condition which is quite common among sick elderly patients admitted to ICU. Multiple factors contribute to this brain disturbance: infection, renal failure, pain medications and overall metabolic derangements including electrolyte misbalance. The list of precipitating factors goes on and on. Preexisting dementia is a big risk factor.

The mood in the conference room is tense. The family is visibly distraught and frustrated. Making a statement like “It is not surprising that your father/husband developed this condition since the brain is often affected when the rest of the body is sick” may ease the tension a bit. Understanding that this is quite common might make the family feel somewhat better.

Acknowledging that “yes, the pain medications that are being appropriately given to the patient might contribute to this condition as well as the kidney failure, infection, electrolyte disbalance…”

It is also important to outline the likely course of the condition by saying “Once overall clinical status has improved and his kidney function returns to normal and the infection is controlled, we will see a gradual return to the baseline”, thus, repeating the clinical concept again to facilitate understanding and retention.

At the end of the conversation the family was quite comfortable with the explanation and the treatment plan. The family expressed their understanding of the patient’s condition and precipitating factors. His wife also admitted that even though he has never been diagnosed with dementia, “his memory is not what it used to be”.

On the fifth hospital day the patient’s condition started to improve. His neurological status later returned to baseline. Hi was discharged home in good condition.

For those of us living in the Midwest of the United States a sump pump in the basement of the house is a necessity. The sump pump keeps the basement dry by pumping the accumulating water out.

So, what do a sump pump and your heart have in common?

Both pump the fluid (blood in the heart’s case) from point A to point B. Beyond that, there is not much in common.

Comparing the heart to a sump pump is a good analogy when describing congestive heart failure. It is often difficult to understand, for the person with no medical background, why the lungs fill up with water when the heart fails.

Trying to explain the underlying mechanism including the rise in the hydrostatic pressure may only confuse the patient. Using the sump pump analogy, for those who knows what sump pump is, is not only easier to understand, but easier to remember.

This is not to insult the patient’s intelligence. You should not even try to explain to me the intricacies of an internal combustion engine, even though, I drive a car every day.

In addition to using analogies to help the patients understand and remember, using graphical tools might be helpful as well.

I was not born an artist, yet I can reproduce a very simplified drawing of a human organ or system. I often realize that the patient is pretty much clueless what I am talking about until I literally draw a picture on a piece of paper or a white board.

Once, I had a patient who carried around a piece of paper with my drawing on it. She was using it to explain other people what was going on.

Obviously, different analogies and associations will work for different people depending on the educational level, social background and even religious beliefs. For example, patients from Florida might have no idea of what sump pump is and, thus, this analogy will never work.

Analogies and associations might also have an adverse effect. I once had a patient who refused to take the anticoagulant Coumadin since he thought of it as rat poison. He simply could not get over it.

It is only half the battle to make a diagnosis and develop a treatment plan. If the patient does not stick to this plan due to a lack of understanding or even lack of trust, the effort is wasted.

The role of autopsy in the medical profession is difficult to overestimate. Western medicine takes its roots from comparative studies between patient’s symptoms and the findings on autopsy.

Participation in an autopsy was one of the most valuable lessons from medical school and residency. If you participated in the patient’s care, there is no greater educational tool than witnessing the postmortem exam. It is especially true if the cause of death was unclear. And even when you are sure what the patient died from, getting insight into how things look inside our bodies is still useful.

The rate of performing autopsies in the United States and worldwide has been declining for decades. There are multiple factors, both on the patient’s family and the healthcare provider sides, which contribute to this decline.

Some argue that with the improvement of the imaging technology the diagnosis and the cause of death are more certain in most cases. Yet, the studies find that there is disagreement between pre and post-mortem diagnoses in almost 30% of cases.

Unless the autopsy is mandated by the coroner - typical for homicides, suicides and cases with unclear cause of death, the attending physician has to obtain consent for the autopsy from the family. A study conducted in Ireland shows increasing physician’s reluctance to obtain consent.

Some of the physicians are concerned about the legal aspect of an autopsy and are afraid of being subjected to a lawsuit if the autopsy is conducted. Once again, research shows that there are, actually, fewer lawsuits filed after the deceased had an autopsy. It was shown that even in the cases of disagreement with the pre-mortem diagnosis, the family is less likely to file a lawsuit. It seems to provide the family with closure after the death of their loved one.

Many physicians cite family’s refusal to provide consent for an autopsy as one of the biggest obstacles. Several studies focused on the patients families’ attitudes toward an autopsy.

Many families do have concerns for the body integrity after an autopsy. Some families are afraid that an open casket burial is simply not possible after an autopsy. The families should be educated in these cases that autopsy performed in a respectful manner with no disfigurement to the body and that an open casket funeral is still possible. The concerns that the funeral is going to be delayed are generally not true as well.

Interestingly enough, it was found that the patients from more affluent and educated families are more likely to undergo autopsy than the patients from less fortunate families. Some researchers, though, suggested that the difference could be explained by a higher rate of possession of automobile and life insurance among affluent patients. Some insurance policies require an autopsy before the payment is made.

In terms of the relationship between race, ethnic background and the rate of autopsy, the data is somewhat contradictory. Some studies state that the patients of African-American and Hispanic origins receive autopsies more often. Same studies suggest that the difference could be explained by a higher rate of homicides and violent crimes among these groups, which leads to coroner mandated autopsies. Some researches also suggested that a general mistrust to the medical profession among African-American and Hispanic families leads to a higher rate of requests for an autopsy.

Other studies found the exact opposite connection between race and the rate of autopsy.

There are, obviously, religious concerns as well. Most religions, though, do allow autopsies one way or another.

Simply practical concerns and the refusal of the major insurance companies to cover autopsy contributes to the decline as well. If the patient dies in the hospital, the autopsy is often free to the family and the hospital pays the bill. If the patient dies at home or at a nursing home, the autopsy can cost the family as much as $2000.

There are many other factors that contribute to the decline in the rate of autopsy. It is simply beyond the scope of this post to cover them all. Autopsy is a valuable education and research tool and the training of the future generation of doctors might simply not be complete without it.

When I was a medical student, I was fascinated by the skill of older physicians to make a diagnosis and describe a complicated pathology just using the physical exam skills. For centuries the main three components of the physical exam including auscultation (listening via stethoscope) palpation (feeling with hands) and percussion (eliciting sounds by tapping) were used to make a diagnosis.
It takes years of practice and experience to perfect that skill.

The recent explosion of medical and information technology has changed the ways we make a diagnosis. The issue has become not how to get enough information but how to interpret the abundant data available via multiple tests and studies.

As the technology evolves, so is the way we interact with the patient. Portable ultrasound allows us to “look inside” the patient right there at the bedside, making an instant diagnosis of an effusion or evaluating cardiac contractility in real time. The patients are well aware about the medical technology available and often request a specific test before the physician even had a chance to examine the patient.

It has been a few years since I talked to a cardiologist about heart sounds and murmurs. We discuss the results of a cardiac ECHO and cardiac catheterization. Those tests provide us with far more diagnostic information than a plain auscultation.

The future looks even brighter. Genomic testing will allow us to look inside the “original code” of our bodies, making a diagnosis before the disease process has even started.

So, is there a role for a physical exam in contemporary and future medicine?

There is no doubt that we will have to change our ways of practicing medicine. It is unlikely, though, that those tried and true skills will go away completely.

Many patients still feel that the interaction with a physician is not complete until the doctor laid his hands on the patient. In many cases, it is a “make the patient feel good” approach. Yet, we know that in medicine the perception could be the reality and the psychological component to many diseases is difficult to underestimate.

Despite the rapid availability of very reliable and informative tests like XRs, CT scans and MRIs, nothing beats your stethoscope or your hands when the situation is truly urgent. It is “poor form”, for example, to make a diagnosis of a tension pneumothorax by a chest XR. In an even less dramatic circumstance, detecting new wheezing or rales on a lung exam or a new murmur on a cardiac auscultation will have a significant diagnostic value.

Sometimes, you do physical exam simply because you have to. In some cases you are not going to learn anything new by dropping a stethoscope on the chest of the ICU patient who has been there 2 months or more. Yet, it is a necessary “ritual” to be able to write a billable note for Medicare. Not doing it and documenting it for the purpose of billing is a fraud.

In conclusion, the face of medicine will change as the technology evolves. It is unlikely, though, that the basic physical exam is going to be completely eliminated as a diagnostic tool.

Physically restraining patients while they are being treated in the hospital sounds like a bad idea or at least a big deal. And it is. Nobody likes to do it, yet in most cases, it’s unavoidable.

Often it is done for the patient’s own safety. Confused and disoriented patients tend to pull tubes and catheters and climb out of bed. I have seen patients bleed after they pull out their IV catheters and rip out Foleys with a balloon inflated (the later is also very painful)

In the current healthcare environment when nurses have to attend to more and more patients, it is becoming a choice of having to stay at the bedside all the time to watch the patient, which is clearly impossible, or restraining the patient.

The attending physician has to sign a restraint sheet on the daily basis to confirm that restraints are necessary.

There are several types of restraints that are being use in the hospitals. The most common one is a wrist restraint . The patient’s hands are tied up in bed. Most confused/agitated patients and patients requiring sedation on a ventilator have these. In later case it is done to prevent the patient from pulling the breathing tube.

Chest restraints look like a vest that is tied to the bed or chair. This type is for more cooperative patients who sometimes “forget” to call for assistance when trying to get up. Once again, this is done for the patient’s own safety to prevent falls.

Less commonly used types of restraints include 4-points leather restraints for extremely agitated patients. This is as bad as it sounds – arms and leg tied up to the bed with leather bands. After putting somebody in 4-points, the restraint flowsheet should be signed every few hours by the doctor (hospitals in US).

Mittens restraints look like mittens that prevent patients from scratching, pulling etc. Usually, those are used along with wrist restraints.

Some really obnoxious patients also require a face mask (usual medical face mask) to prevent them from spitting at the staff.

The truth about restraints, though, is that most physicians sign the orders automatically, without verifying the real need to restrain. It is not uncommon for the doctor to sign orders for several previous days worth of restraints without even seeing the patient.

This is not to say that restraints are being used inappropriately. Nurses do an excellent job of deciding who should be restrained and how they should be restrained. As I mentioned above, restraints are an inevitable tool we use to keep patients safe in the hospital.

Signing the order for restrainets has become one of those formalities that should be done in order for the hospital to get through JACHO certification. Having physicians sign restraint orders does not identify or eliminate the unnecessary restraints; it just adds one more thing to the pile of paperwork to do.

What often does work is for the patient or the family to inquire about restraints during the physician’s visit. In many cases the need for restraints is obvious. Nobody wants to see their loved face down on the floor or bleeding after pulling a urinary catheter. In these cases the need to continue restraints should be explained to the family.

In other cases, “wait and watch” might become a reasonable approach to see if the patient needs further restraining.

As the population gets older, patients with dementia will become more “prevalent” in our hospital wards. With more confused patients being admitted to the hospital, restraints will be used even more often. This is an unfortunate, but yet true trend when it comes to restraints utilization. Adding more paperwork and hassles for the physicians will not solve it.

The relationship between ER physicians and the hospitalists is often…let’s say complicated. The two physicians often have a completely opposite agenda. In a nutshell – ER doctor thinks that everybody coming to ER should be admitted to the Hospital. The hospitalist, in contrast, thinks that there is never a good reason for an admission.

Let’s look at things from the ER physician standpoint first. The ER doctor has to facilitate patient flow in the ER. Otherwise, the waiting room will be overflowing with people, waiting time will be long and the patients will be grumpy. You send the patients out of ER either by discharging them home, if they are not too sick, or calling the hospitalist to admit them, if there is a good reason for it. This sounds simple enough. In real life, though, there are a lot of patients falling into the grey area. The patient might not have a good indication for an admission, yet not quite ready to go home. And that’s where the problem begins – the ER doctor is not comfortable sending patient home, the hospitalist does not see a good reason for admission. The problem is made even worse by a heavy workload for both physicians.

From the hospitalist’s perspective, the patients are often admitted to the hospital for no good reason. Things are rarely straightforward and sometimes it takes time and effort to do the right thing for the patient. Talking to the patient, looking into the old medical records and communicating with the patient’s family takes time. If the ER physician is not quite sure what is wrong with the patient, calling the hospitalist IS the path of least resistance. Some ER doctors even get creative when trying to “sell” admission to the hospitalist. There is always a mysterious pneumonia that nobody can see on the chest XR, otherwise, known as ER pneumonia or NOmonia. Some patients are being admitted for obstipation or “failure to thrive”. Occasionally, the ER doctor will tell you that he has no idea what’s wrong with the patient and is just not comfortable sending the patient home.

I don’t know how many times I was told – “Just watch the patient overnight”. The thing about “watching somebody overnight” is that it often requires the same (or even more) amount of time as a regular admission. The next day, somebody will have to discharge the patient, which takes yet more time for something that could have been done on an outpatient basis.

This is a hospitalist blog and I might not be entirely fair to the ER doctors. I welcome ER physicians input into this problem. After all, why can’t we all just get along?