Medicine For People!

March 2019

Columbo TV Promotional Photo
By NBC Television - eBay itemphoto, Public Domain

Slow Medicine: Columbo and Me

Columbo made me a better doctor. Remember Columbo? The bumbling detective played by Peter Falk, who seemed never to know what he was doing, turning away from the reluctant witness with his famous "I'm sorry, just one more thing." He then asked one more apparently stupid question. And the solution came easily.

I am a slow thinker. The 1970s found me in Watsonville, California, often recalling something important after the patient had left the office. My desire to do the right thing overcame my reluctance to look inept, and I would run out into the parking lot to ask the person one more question or tell them one more thing we needed to do. I wished so much I could be like my professors and colleagues who seemed to have the right answer at their fingertips every time. So, I found this somewhat embarrassing until I saw this fictional detective and realized that what mattered is how well you get the job done, not how cool you look.

That leads me to the dirty little secret of modern medicine. Although our academic centers and researchers continue to come up with better ways to take care of people, our ability to put all this into practice falls further and further behind. We're looking better and better, but satisfying people less and less—because we are going too fast.

Medicine Fast and Slow

Fast Medicine

At Duke Medical School, all my superiors including professors, residents and interns seemed to have the answers at their fingertips. At this point in my career, yes, I can pull a lotta stuff out of my head. I also know that if I'm not spending significant time behind the scenes with my journals and textbooks, I'm not doing my job. And so it must have been with my professors all those years ago.

Aside from that, the doctor of today must operate from a much larger information base than did my professors.

When I graduated in 1969, there were about 400 unique drugs. By that, I mean unique chemicals approved by the FDA for medical use.1  Today there are about 1600. Most come in several dose forms, brands, combinations, and formulations such as capsule, tablet, timed-release tablet or capsule, cream, inhalation, injection or whatever. Each has the potential for side effects, and each can interact with one or more of the others.

Got that covered?  Then try keeping up with the about 220,000 medical papers published each year.2

Your doctor works with a fire hose of new information.

Think of what you and your friends consider optimal medical care and compare that with these late-breaking guidelines:

Elderly people with diabetes fare better if we grant them some latitude in their blood sugar control. When we try to make their numbers entirely normal, too often people develop low blood sugar, which can result in falls and emergency room visits.

The older long-duration insulin, NPH, is in some ways better than the newer high-priced insulins, glargine or detemir.

Don't start blood pressure medication for an otherwise healthy older person until they exceed 150 systolic (the top number). And don't get the level down to a young person's blood pressure—your elderly patient won't live as long.

Colon cancer screening: there is no evidence, for the average person, that a colonoscopy is a better screening method than an annual test for blood in the stool.

MRI can cause more problems that it helps for many people with joint problems. Let the specialist decide.

Ask your friends if they've heard these latest guidelines. If not, the research goes to waste. Patients' time and doctors' time goes to waste. Our potential for optimal health goes to waste.

That's just one way that today's medicine is fast and wasteful. Here's another way, at least for the primary care doc. Policymakers in the insurance industry over-estimate what a human being wearing a white coat can do in a few minutes. Your doctor is expected to detect any life-threatening illness, most medical conditions, abuse in the home, malnutrition, sexual dysfunction, hidden depression, concerns about gender identity, cognitive decline, and then, too often, complete a Prior Authorization form to see if the insurance company will cover the diagnostic tests and treatment.

In addition, your doctor's employer expects medical record-keeping that not only describes your care, but also must also maximize reimbursement from the insurance company. The doctor must do that record keeping in front of you at the expense of your encounter, or do it later at the expense of her family time.

Any healthcare worker can end up on a fast clock. A nurse who worked at the long-term care facility across the street from my office told me that administration allotted them 8 minutes to insert a urinary catheter. This might work if the patient had been an Olympic athlete used to speed and physical discomfort, but when applied to people nearing the end of their lives, an 8-minute urinary catheterization is medical assault and battery. This nurse, as did most of her colleagues, ended up taking more time on these tasks, clocked out after 8 hours as required, and then stayed late to get all her tasks completed on her own time.  

Slow Medicine

Fast medicine is wasteful medicine. The need for thoughtful medicine is the reason our clinic stopped contracting with insurance companies more than 20 years ago.3

How slow can medicine be? On a few occasions, I have asked the patient to close their eyes with me and sit in silence for a few minutes in the exam room. On many occasions I have given patients homework to complete before returning for further collaboration. Frequently family members come to the office to add their observations and receive their own coaching as caregivers.

As a young doctor, I sometimes spoke so quickly that people could not follow what I said. Now I speak much more slowly. People have real concerns, real questions. They are individuals, not members of a herd. Each person has this or that family history, eats this or that, exercises this much or that much, and may or may not have plans to do better. They may have had unpleasant experiences with pharmaceuticals or doctors. They are the important person in the room, not me.

So I often pause every few sentences to check if people are following the story. Everyone wants to understand. We doctors must give our patients the time to understand things. If the doctor speaks too quickly, the doctor may as well not open his mouth at all.

The Corporate Tower and Lieutenant Columbo

The guy in the corporate tower isn't aware that the patient may have trouble finding words, may have misinformation that must be corrected, may be long-winded, or may be hesitant to speak up in the presence of the doctor. It takes more than 8 minutes to insert a urinary catheter. It takes more than 8 minutes for almost all medical encounters of any consequence.

To keep difficult work as manageable as possible, we remain an out-of-network provider—and leave relations with the people in the corporate tower to our patients.  Our sole responsibility is to get your medical work done right.

You Are Not a Widget

It is so tempting to hope that the doctor do something to shield us from the consequences of our health choices. It is so tempting to hope that we can sit in the recliner a little longer and put off that exercise, that we can be careless about what we eat, and that the doctor or dentist can make it all come out okay.

And we all know, really, in our heart of hearts, that those hopes are futile. When it comes to our well-being, the doctor's care contributes 10% and our lifestyle contributes 40%.4

Sometimes we are working with the 10%, and we docs can come up with the quick answer in the time allotted. More of the time we're in the 40%—collaboration territory; the place where haste makes… —well you know what it makes.

Sometimes there is no substitute for a curious detective—either Columbo or your doctor—and enough time.

 

 

Endnotes

[1] https://www.raps.org/regulatory-focus%E2%84%A2/news-articles/2014/10/how-many-drugs-has-fda-approved-in-its-entire-history-new-paper-explains

[2] https://www.nap.edu/read/10866/chapter/28#446

[3] http://www.rienstraclinic.com/health-info/general-interest/politics/single-payor/

[4] American Family Physician March 15, 2019 page 357.

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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.