QA

This morning I am up at the crack of dawn for the monthly quality assurance meeting. It is my favorite meeting of the month and I am not being facetious. I have been doing this for, let me see, almost sixteen years! There is more painless learning in this one hour than any other time of the month. The only time that it is painful is if one of my cases is being presented.

The physicians that serve on this committee receive no monetary compensation for what amounts to about six hours of work each month. The reward for serving on this committee is that a lot like medical school and residency, you find out what will get you in trouble second hand.

It works like this:

The hospital has a list of "quality indicators." Things such as excessive blood loss at a delivery or a surgery, the patient developing a complication, the baby developing a complication and so on. I believe you get the picture.

Now these things happen. And interestingly enough it is usually not the "quality indicator" that got the patient in trouble since everyone is doing everything they can to keep these things from happening.

No, what gets patients and ultimately doctors in trouble is some little, seemingly insignificant occurrence that no one noticed. Here too is the pay off for those of us on the committee.

I will give you an example. Early in my stint on this committee there was a Cesarean section patient who developed a fever. She received the correct antibiotic at delivery to protect her from infection. The doctor involved saw her when she developed the initial temperature spike and every spike after that for four days and then her appendix ruptured. She got peritonitis, an inflammation of the lining of the abdomen and had to undergo another surgery. This is when the appendicitis was diagnosed.

Now the chance of appendicitis after a C-section is probably less than one in a thousand patients but this whole thing happened to a very good physician that I respect a great deal. It also happens that I don't ever do a C-section without at least a glance at the appendix to make sure that it looks alright.

Every meeting is like that. Some great pearl of a pay off for those hours looking at charts, getting up early, wrestling with the issue of how to make the quality of medical care better for future patients.

Finding a cure

If I could find a cure for one thing it would be uncertainty. It seems to be the disease that plagues humans the most, causes the greatest anxiety, renders much suffering. It is why much is made of living in this moment and not wondering and worrying about the next.

"See one, do one, teach one"

Back at Famous College of Medicine when I was learning to delivery babies the motto of the OB department was "see one, do one, teach one." This was my experience in the first two days of the rotation. We arrived on a Friday and I was on call that night. Paired with another medical student one of the junior residents took us to a delivery room and carefully walked us through a delivery from positioning the patient, to putting on the gown and gloves, to the careful (and artful) act of holding the baby in our non dominant hand while we clamped and cut the cord with our dominant one.

Yes, I trained back in the days where the dads did not get to come to the delivery room. I also trained in a hospital so big and so busy that there was no room for a father in delivery. FID as I was to later learn in my residency program where fathers took a special class to earn a pass to the delivery room.

So, imagine that it is my second day on my medical school OB rotation. At this point in my career I have delivered five babies. I am just beginning to be comfortable with the process. Looking down the hallway I see a nurse pushing a stretcher from the triage area. One the stretcher is a woman with the largest abdomen that I have ever seen. "Delivery doctor! I need a delivery doctor!" the nurse calls.

Delivery doctor. That's me. I run after her and in to a delivery room trying my mask on as I run. After we get the woman over on to the delivery table I check her cervix and note that it is completely dilated.

"I gotta push doc!" the woman pants.

"Not yet!" I yell. "Let me get my gloves on." The art of gowning and gloving myself is as difficult as delivering the baby.

About the time my gloves are in place her bag of waters breaks and out comes a tiny four and a half pound baby. I suction the baby's nose and mouth, clamp and cut the cord and put the baby on the woman's abdomen just as she says, "There's another one coming."

"No, no," I say. "That is just the placenta."

"Doc, I have had babies before. Trust me. There is another baby coming."

At that moment I look down and see two tiny feet at the vaginal opening. It dawns on me why this woman's abdomen was so large and yet the baby I had just delivered was so small. She is pregnant with twins and the second one is breech.

"Get me a resident!" I yell. See on, do one, teach one did not extend to twin deliveries or breech deliveries either.

Again I ask the patient to please just breathe for a moment while I try to do the same myself. Suddenly through the door comes a resident I have never seen before. He looks at me and in a very self important voice says, "What have you got here?"

"Twins. The first one is delivered and this one is breech." I say stepping aside.

"Shit!" he screams. "I am a family practice resident and I have never delivered a breech baby." Then he yells, "Get a resident in here!" I guess he had done something that I had not which was read the chapter on Multiple Gestations in the textbook.

At this point the patient is no longer able to help herself and she pushes. I step up and delivery a small breech baby boy, who after I suck out his nose and mouth begins to scream his head off as if he knew how ill prepared these two doctors were for his arrival.

Now having read all the complications of both multiple gestations and having had more than one complicated breech extraction, I still marvel at how I managed to do a breech delivery before I ever even saw one.

The ability to cut

As a medical student I heard the surgical residents brag "the ability to cut is the ability to cure." While I enjoyed the way surgical patients tend to improve much faster than those receiving medical therapy I have also achieved a healthy respect for the risk of complications from surgery. I understand why patients wish to avoid surgery when possible. Yet there is a subset of patient that seem to enjoy having surgery.

Take this case of a woman who has been my patient for the last ten years. I have operated on her four times and delivered two children for she and her husband. I am not proud of the four operations. I feel that two of them were probably avoidable. It is difficult for me to explain especially to non-physicians how I came to do these two probably unnecessary surgeries but a clue comes from the last encounter I had with this woman.

The patient walked into my office looking the picture of health and stating that she never felt better four weeks following her latest surgery. Looking at her operative incision which is now well healed I said something like, "You look great and you seem to be doing great, too."

"Yes," P exclaimed, "I do feel great. I think this will last at least a couple of years.

"A couple of years? You shouldn't ever have to have surgery again!" I exclaimed.

"No, I am sure that I will get some adhesions [scar tissue in the abdominal cavity, a known complication of abdominal surgery in about 15% of patients], " was her quick reply.

"Well, " I said thoughtfully, "I think you have about an 85% chance of NOT getting them."

She frowned. She enjoyed her time in the hospital away from her children ages five years and 18 months. Enjoying time in the hospital as a patient is something that I fail to understand. It seems like a difficult way to get a vacation. Also from my experience on patient side of it surgery hurts. I don't mind confessing that I don't like needles and I really don't like tubes in places that I am not use to having them.

All this said, the patient is now "well" and no complications were encountered. At least not yet. This surgery was successful. I can and do feel good about that.

What doesn't kill you

In the back of my mind is the quote, "What doesn't kill you will make you stronger." I believe I got that saying from one of the physicians with whom I have practiced for the last eight years. Given the past two years I am hoping that it is true.

This hope comes for two reasons. The first is that the past two years have almost killed me. I have never found the practice of medicine to be so difficult. As I have often alluded to the practice of medicine seems to be changing. Many patients seem to believe that medicine can do everything including make them beautiful, skinny, and happy and all at the same time. While I don't disagree that ugliness, obesity and depression are diseases, they are not the only ones that I was taught to treat and no one taught me a therapy that would negate patient responsibility where their cure is concerned. Also while medicine has always been an art and a science it has now become big business as well with the physician patient relationship a mere by product rather than the center of this enterprise.

All that said, I am leaving private practice. At least for now. BEFORE it kills me. Practicing as an OB hospitalist will take its toll too but for few days each month. Once I catch my breath, who knows. A.J. Cronin, Robin Cook, J. Michael Crichton, Atul Gawande look out!

Work worth doing

I have often been asked if I keep track of all the babies that I have delivered. The answer is no. When I was a third year medical student in the largest county hospital obstetrical unit in the country I preformed forty deliveries by myself in just under four weeks. This may sound like bragging and I am. I also use that figure to illustrate that the motto of the obstetrical service "see one, do one, teach one" was not far from the truth.

At the end of my medical school rotation in obstetrics I decided to stop counting deliveries. Each delivery is very special. I found that I enjoyed remembering them individually and not as the collective whole their sum would represent.

However, I do count in short intervals. I vividly remember the day I did six term vaginal deliveries when I myself was nine months pregnant pregnant. I hauled my big pregnant belly up and down the back stairs to my office that day just expecting to be in labor myself at any moment. I was even grumpy when I delivered a patient due two weeks hence as she and I had both anticipated that my baby would arrive before hers.

I remember the night that I did three surgeries in a row for ectopic pregnancies. Since things seem to arrive in threes I slept like a log after the final one was in the recovery room. It was three AM when I crawled into bed and I felt that there could not possibly be another patient with an ectopic pregnancy out there with my phone number. Fortunately there was not.

Today my record will be dead babies. Intrauterine fetal demise or IFDs as the residents call them. The first was just after 7 this morning. My hospitalist shift began at 7 and I arrived a bit early due to anxiety at what might await me. Sure enough there were two IFDs in labor and delivery when I arrived. I have never had two in one day before. Thinking about this and waiting for board checkout (the procedure for passing off the patients present to the new on call physician) I was called to the emergency room when another obstetrical patient who had just arrived and was delivering. Her baby was dead also.

I remember what I was told in medical school. "If it were easy, then anybody could be a doctor." This is true. The work here is hard not only physically but emotionally as well. These people make me realize how easy my life has been. And that hard work is worth doing.

At what price?

Over a decade ago when my mother was hospitalized to have her lung cancer diagnosed I was somewhat chagrined to see the name of a 74 year old heart transplant patient listed in a room down the hall. The health information privacy act was not in effect yet and I happen to glance at this man's age, post operative diagnosis and profession as I walked past the nursing desk one day. My mother was six years younger, probably much more frail and had retired thirty eight years before when I was born. As America enters the debate over health care yet again, I think back to the questions that I had when I noticed that bit of information about a random patient in 1991.

You see, until the moment that I saw the patient's age, I believed that organ transplantation was offered only to those 60 years old and under. Well maybe, I thought, he was able to buy out of the system. That was only a fleeting idea as I noticed he was a retired minister. We were in a denominational, not of profit hospital so he probably had some influence. Again, no problem. Except that health care is a pie, even if it is one that America has tried to expand, someone paid all the expenses that went with the cost of the heart transplant surgery, recovery and on-going care.

My mother's condition was terminal. I have shared before that I had that realization the moment I saw her fingers some weeks before. Her palliative treatment also had a price tag. The radiation alone she received cost thirty five thousand dollars. All this was paid by a health policy that my father's former employer paid for as a part of my father's retirement benefits package.

Looking back I feel that the care my mother received was worth the cost. I believe it would have been worth the price if I had paid it out of my pocket, which I am not sure my parents would have allowed if this was the way our scenario played out. We had five months to prepare for her death. My mother had some good days and actually stopped her treatments when she determined they were more painful than she felt they were worth. Hospice, which Medicare covered, was extremely helpful in the last few weeks of her life and afterwards as my father began to deal with life without my mother.

Yet, I have always wondered about a heart transplant in a 74 year old. Perhaps if it were less of a mystery. Did the recipient believe it was worth it in terms of the suffering? What was his quality of life? How long did he live? What were his families thoughts. If I knew the answers to these questions I could better measure them against the 40% of children who did not receive immunizations in our county that year or the women who had to wait all day for each visit in their obstetrical care so they went to work instead unable to lose a day's paid to receive their "free" care.

I hate to be the bearer of such tidings. I venture to guess that all of us glancing at this blog can do the math. The toughest part of the health care debate will be the rationing of health care. Patients, physicians, hospitals, third party payers all need to get use to that fact and move on to making choices.