What is good medical care?

Is good medical care appropriate, evidence-based care or is it what makes the patient happy? Ideally you would have both, but patients understandably prefer the latter. A quote from the New York Times' health blog (in response to "Six Rules Doctors Need to Know,," by Dr. Rob):

I can report I had my first positive medical experience in 12 years–at Urgent Care. It was last weekend. I did not call my primary doctor of record because he leaves the machine on during business hours, does not have same day appts, of course does not have Sat appts, and would not intermediate when I could not get information from two specialists during a serious episode. Anyway–at Urgent Care, the physicians asst listened to me for 10 whole minutes, smiled at my jokes, asked about my ruined eye (the serious episode mentioned before), and then even asked what antibiotic I wanted. I left with a sheet containing my test results and the line: I hope you feel
better soon. No doctor has EVER said that to me. The clinic even called two days later to see if I did feel better (the vets here do that, not the doctors). Anyway–repeat after me: Urgent Care!

So the poster has some legitimate gripes: Her doctor's office is not open off-hours and hasn't responded well to some of her needs. So she goes to her friendly neighborhood PA, who is such a great health care provider that he smiles at her jokes and gives her paperwork stating he hopes she feels better soon. All of this is great.

But what sticks out to me is that he asked her what antibiotic she wanted. Unless she's a physician herself, how could she know what antibiotic was appropriate to her condition? Isn't selecting the most appropriate treatment for a medical condition the job of the medical provider?

I read a similar post on the New York Times blog a few weeks ago. It was a patient complaining that her regular doctor didn't prescribe her antibiotics for her sinusitis, so she went to a retail clinic and in ten minutes was out the door with her prescription for, you guessed it, antibiotics! Even though the new recommendations for sinusitis state that antibiotics should only be used for severe cases, the NP at the retail clinic was all too happy to pull out her prescription pad and make some money for the pharmacy she works for by prescribing, in all likelihood, one of the more expensive brand names.

We definitely need to spend more time educating our patients about why we choose the treatments we do, and teach them that sometimes antibiotics do more harm than good. And maybe we should smile more at their jokes and have more access for off-hours. But when a patient's perception of good care is equivalent to offering them a choice of antibiotics, something is terribly wrong.

Fatigue

Yesterday was a long day for me. A long shift on an inpatient floor, during which I spent half the day cleaning up the mess the ED had dumped on me, followed by visits to my own patients in two other hospitals. I have a lot of respect for ED doctors, and I realize you are under a lot of pressure, but this is what you sent to me yesterday:

1. An 80 year old lady with chest pain and weakness and a new LBBB on EKG. She had been in the ED for about 30 hours. Her initial cardiac markers drawn when she initially showed up showed a CPK of 1200 and a negative troponin. She then proceeded to sit in the ED for another 30 hours. She got no IV fluids, no repeat EKG, and had no repeat cardiac markers sent. Then she was admitted to my non-telemetry floor.

2. A 70 year old lady who came in with decreased appetite, abdominal pain, and weakness. I give you credit for doing a rectal exam. But you didn't notice the new onset renal failure; creatinine of 6.6 (last recorded several months ago was 1.5). You didn't put in a foley. You didn't give her any IV fluids. She sat on your service for 15 hours without even getting the most basic care. You also don't seem to have noticed the enormous bruise on her back, her persistently saying "he hit me, he beat me, I don't know why," or the vesicular lesions on her vulva and the tears on her vaginal walls.

3. A 75 year old gentleman presenting with altered mental status and new onset aphasia. You did do a chest x-ray and a UA and some basic labs. But if you'd done a head CT you might have noticed the new-onset hemorrhagic stroke and you might have had more luck getting radiology and neurology to pay attention to the patient, as you are, after all, the ED.

I feel bad for the other 15 patients I was in charge of yesterday. They didn't get the care they deserved because I was busy calling radiology for stat CT's, putting in foleys and IVs because we only had 4 nurses to cover 35 patients, and drawing stat labs and bringing them myself to the laboratory because our hospital has decided to stop paying people to transport specimens.

Fortunately the day ended well. I visited a patient of mine who is hospitalized at a nearby hospital who is slowly recovering from contrast-induced renal failure, and then the highlight of the evening was visiting my African patients on the OB ward to meet their new daughter (who I unfortunately couldn't deliver as I was busy dealing with too much elsewhere).

I got home at 10:30 PM, but I know I did right by my patients yesterday (at least the ones I had time to really take care of).