Wartime Medicine

Medicine in the context of war spurs innovation while staying streamlined and minimalist. Several mainstays of modern medicine have been developed because of battlefield medicine - the concept of triage was beget by the need to do the greatest good for the greatest number of casualties on the battlefield when resources were overwhelmed, the modern blood bank and the use of morphine for pain management emerged out of necessity in WWII, and the use of air medevac by helicopter began to be implemented in the Korean War. Medicine in the military is a trial by fire; war produces trauma with mechanisms of injury often unseen in the civilian world - and military physicians and their teams have to manage these extreme cases with limited resources, producing new technology, protocols, and procedures.

Modern war medicine has produced a new kind of progession in the care of critically wounded soldiers in the form of "damage control", where performing the minimum intervention necessary for stabilization is preferred to immediately doing everything possible. Forward Surgical Teams (FST's) follow closely behind combat troops and are able to deploy a functioning hospital with surgical suites in an hour with just a handful of backpacks. They are the first point of surgical intervention following EMS battlefield casualty evacuation, and they exist to stabilize casualties until they can receive definitive care at a later point. The frequent major traumas caused by recent prolonged wars, though tragic, have spurred changes in protocols that will improve outcomes for all. For example, the onslaught of severe limb injuries in Afghanistan and Iraq have shown that rapid, appropriate tourniquet use can significantly improve mortality. Improvements in extrication and transport time in battlefield medicine have encouraged their use. In civilian emergency medicine, the use of tourniquets is discouraged and used only as a last resort to control bleeding. In cases such as these, wartime medicine can overturn conventional medical wisdom.

The Doctor-Patient Relationship

Doctors are in a unique, influential, poweful position in taking care of patients. They are priviliged and trusted with intimate details of their patients' lives with the expectation that they will be understanding and professional in advocating for the most appropriate treatment plan for each patient. Treating the patient requires an understanding of their disease and their personhood - their desires, beliefs, and worries, in addition to having a warm beside manner. But the doctor-patient relationship can vary widely by specialty, and it can manifest as anything from "following someone’s hypertension for 10 years" in internal medicine or family practice to "what you have when someone gives you a chart with a patient’s name on it" in emergency medicine. In radiology, pathology, or any specialty that does not involve much patient interaction, there is no doctor-patient relationship - but as we have seen, some doctors in these specialties can come up with interesting ways to connect with their cases as human beings simply through looking at a picture.

A healthy doctor-patient relationship can make every difference in patient compliance, but its effectiveness has been limited. Recent developments in health care have changed the game completely by sterilizing the interaction between doctor and patient. Declining time spent actually speaking with patients, the emergence of the informed patient, and fear of litigation, among other things, have created an environment in which a new kind of doctor-patient relationship must form. Striking the correct balance of efficiency and warmth in this system is a challenge, and one that may become easier with time as health care reform is legislated.

Big Pharma

This week we explored the aggressive and sometimes insidious tactics of the U.S. pharmaceutical industry. In clinics, big pharma makes its presence known with a constant stream of sharply dressed, attractive drug reps. Ads and promotional materials for drugs are frequently found strewn about clinics: pens, clipboards, posters, etc. In the media, the pharmaceutical industry has leached into television with consumer-directed advertising. In one physician's office where I worked, news of a drug (or medical device) rep coming through the office spread joy and thoughts of free lunch throughout. Frequently, the reps bought the entire office lunch for the chance to give their spiel. I asked one doctor how he felt about the reps and whether he actually seriously considered their peddling; he said that takes what they say with a grain of salt, but that he cannot possibly keep up with all the current literature, so on some level there is little fact-checking. He continued, saying that drug reps pushing their products are a reality of modern medicine. For the particular rep that visited on the day I asked, he expected nothing more out of the encounter than free lunch. I see no moral imperative to accept their gifts, nor to do anything in return for them given the thinly veiled expectation of reciprocity.

Private Practice

Currently, the number of doctors entering private practice is decreasing while the number of doctors taking salaried positions is increasing. Do the benefits of running your own business and being your own boss outweigh the stability and certainty of being a salaried physician? I have worked for small business owners for years and have done some freelancing myself, and I understand why this trend has become so prevalent.

Running a business adds a lot of additional stress to an already stressful job and it is not conducive to a favorable work-life balance. Additionally, most medical students never receive training in managing a practice and must pick up business-savvy skills from other sources, and apply them to build a referral network. Taken with the start-up costs associated with getting a practice off the ground, entering private practice seems a daunting task. However, the independence and freedom of choice that comes with running the show and managing/scheduling patient care as one sees fit (within the confines of necessary bureaucracy) can be alluring for some.

Ronald Arky, M.D., of Harvard Medical School, posits: "The patients you see in either system can be the same. The difference is all about the money and where it goes". While these differences are profound, the most salient difference for me is the extra responsibility and worry of running a business. Group practices, where there is division of responsibility, are an interesting solution to the problem of always having one's livelihood on your mind. I am all for "Be[ing] adventurous. Be[ing] willing to go out and earn your living. Be[ing] willing to take chances", but I also want the peace of mind that comes with a salaried position.

Shadowing

For my shadowing experience, I spent one Saturday night from 10pm to 3am at RIH ED following around a second-year resident in Brown's EM program. We spent most of our time bouncing between the ED's six critical care rooms and following up on labs and imaging studies. Over the course of the night, I watched one patient die while another balanced on the brink of death; I stood by as a doctor told a patient that his cancer had most likely returned; I was given quick tutorials in the radiology and CT suites, and I got a great sense of the ebb and flow of ED.

The resident was soft-spoken and calm, with a cool head. It seemed like he had great relationships with the team of ED personnel responsible for patient care. Despite the chaos and emotional toil of a weekend night at the ED, there were times when laughs could be had all around - from security to the nurses to the techs, everyone got along seamlessly in mutual respect. Everyone had a job even in the most complex cases, and shadowing the resident reinforced the concept of emergency medicine being a 'team sport'. Trauma teams, medical teams, and consults from neurosurg and cardiology all assembled in my time in the critical care rooms at Rhode Island.

The biggest impression I took away from the experience was the level-headedness of the staff amongst the unruliness, the violence, and the onslaught of human suffering. They could not be shaken. Some patients in the ED, many intoxicated and/or injured, take their inappropriate behavior to the nth degree. No one is ever safe from certain patients' vicious tongue lashings or spat blood. The doctor, as part of the ED team, needs to be able to objectively evaluate and treat these patients with respect after walking away from something as draining as a failed resuscitation. I admire their ability to take the tragedy with the victories all while putting up with the BS.

RIH ED Shadowing

For my shadowing experience, I visited the Rhode Island Hospital Emergency Department Saturday November 7th. There are countless doctors who work there on any given shift, but I stayed mainly in "trauma alley" where the most critical patients are cared for, nearest to the ambulance bay. As it was a Saturday, an overwhelming majority of he patients we saw were intoxicated, complicating their diagnoses and care and often causing the injury or illness that led them to the ED. More than one patient required mechanical restraint either by security or soft-restraints and one patient was given Haloperidol to chemically restrain him and facilitate his treatment. There were numerous assault victims, many of whom arrived around 2 am, when most of the bars downtown close.

This was by no means an unusual situation. I had the opportunity to ask one of the ED residents about what role alcohol plays in patient care and he responded that it causes and complicates far too many injuries whether through drunk driving, poor judgment, or extreme intoxication. During my time there we saw a pair of Rhode Island State Troopers arrive with a patient implicated in a car accident. These officers are often at the ED, but are not privy to a patient's medical information. Dr. Wang, a third year resident explained to me that even if nurses have already taken a breathalyzer reading from a patient, but police must obtain separate permission for this information--permission that most under investigation will not provide.

Doctors in the ER acted coolly and professionally. Although faced with a myriad of bizarre and often belligerent patients they still used "sir" and "ma'am" when talking with patients and were not easily flustered. One doctor, visibly pregnant through her scrubs, had a particularly calm and authoritative demeanor. When a patient began to get violent during their assessment, she belted "security" down the hall and took a few steps back.

In addition to the doctors that I observed and spoke with, there are many other important players in the ED. Security personnel work hard to protect the other workers and patients themselves. At one point a security officer translated for a nurse who didn't speak Spanish, allowing her to better communicate with her patient. EMTs and paramedics also play an integral role in allowing the ambulance triage area of the ED to run smoothly. Many are familiar with the nurses and will help transport a patient or restrain a patient if extra hands are needed. Those from the Providence Fire Department could often be seen grabbing a short break at the hospital with one another while waiting for their next call. Usually they would get a call before they could even get back to their station. Nurses and CNAs had a majority of the patient contact during a patient's stay. They did everything from administering medications to getting blankets and making patients comfortable. A number of times, they had to endure belligerent patients yelling obscenities at them for an hour on end while they did their job. There were even official ER observers who walked through the trauma rooms with high risk teens and emphasized the consequences of risky behaviors behind the wheel and with drugs and alcohol.

ER doctors had to be team players. They worked with numerous colleagues, whether their respective attendings/residents or specialists and, as shift workers, transferred patient care at the beginning and ends of their shift. I heard them often consult one another while making difficult decisions, and even compare general impressions with a few highly experienced nurses. Because it was a generally slow night for the ED, a number of different doctors took time to answer my questions and explaining what they were doing and the rationale behind it. At one point, they motioned for me to follow them into the CT scan and I was able to watch one performed on the head of an intoxicated patient and explained the procedure. I enjoyed the opportunity to see so many different physicians interact with their patients forming patient-doctor relationships rapidly out of necessity.

Alternative Medicine

Physicians should be concerned about the widespread use of complementary and alternative medicine (CAM) -- if only because it's giving them a run for their money. The study we read comparing CAM use from 1990 to 1997 demonstrates equal or higher rates of CAM as compared to visits to allopathic physicians. Such physicians should be asking themselves what they are doing wrong.

Is it a lack of available primary care? We studied a month ago how difficult it is for many patients to access affordable primary care. Too few medical school graduates are choosing primary care specialties and more and more Americans are without adequate health insurance. Alternative medicine offers simple remedies for many of the common chronic conditions for which Americans may be unwilling or unable to seek physician care.

Are physicians failing to address emotional and spiritual needs of their patients? The Eisenberg study also highlighted the number of therapies addressing these less concrete, but no less real issues. With the increasingly limited time that physicians have to spend with their patients, how will they be able to address such complex and intimate aspects of health?

Finally, do physicians settle for a cure over health for their patients? "Cure" has become a mystical and revered goal in medicine as medicine looks to define cures for cancer, AIDs, and other life-threatening diseases. However, promoting health involves more than removing disease. Physicians must also seek to bring patients to a point of optimal quality of life. Our readings on life and mortality clearly demonstrated the deficiencies in our healthcare system regarding the value of a person's final days and weeks as opposed to the length of their survival.

A primary care physician educated in the various forms of alternative and complementary medicine will be better equipped to support their patients who utilize these therapies and more willing to refer patients to such practitioners. They can use CAM to supplement a faulty and inadequate system.