Welcome to HemoDoc, From Doctor to Patient

By Peter Laird, MD

HemoDoc, From Doctor to Patient is a doctor's blog from a patients perspective exploring both sides of the doctor-patient relationship as a source of information and communication between these two distinct groups of people that are nevertheless entwined together in one of histories most interesting human relationships.  As a young physician just out of medical school in the 1990's, I witnessed firsthand the transformation of this time honored relationship into one of less trust and increased antagonism.  Yet, no matter how many barriers are erected between the doctor and their patients in today's new medical paradigms, the interactions between an individual patient and his individual doctor in the confines of an exam room remain largely unchanged and the skills of a physician gaining trust and confidence from their patients is a time honored skill crafted through the ages.

For a new medical student eager to learn the art and practice of medicine, remembering the pioneers of modern medicine is essential to navigating the new medical ethics and practice styles of today. For patients, the need to find a caring and compassionate physician dedicated to their individual needs is an essential component of survival when faced with life threatening illnesses. Often today, the basic tenants of medicine to relieve suffering and promote individual well being is overshadowed by cost containment principles of treating the physician's entire patient population as a whole and not focusing solely on the individual.  This new medical ethics emphasizes the patient population more so than the individual suffocating centuries of advancement in the doctor-patient relationship. Indeed, now in every exam room is the foreign presence of the finance officer as well as the doctor and patient in all diagnostic and treatment decisions.  

Understanding the science of medicine as well as the rights of the patient in this atmosphere falls largely upon the individual patient to act as their own advocate.  The role of patient advocate that the physician has traditionally assumed is now mitigated by cost containment strategies for the entire patient population or patient panel cared for by the physician.  Physicians are compared openly to their peers through statistical analysis of all aspects of their practice.  Those physicians that spend the least are heralded as the champions of practice management though often at the expense of the individual patient. Respect for patient autonomy is falling to the ethics of distributive justice that fails to account for the simple truth that the best medicine is most often the cheapest medicine. 

Examples abound of medical practices deemed too expensive at the onset for general use having been in secondary analysis proved cost effective by their reduction in disease burden and associated treatment costs.  Colon cancer screening initially utilized the stool guaiac as the gold standard, yet when Medicare began reimbursing for screening colonoscopies, colon cancer chemotherapy costs fell dramatically, in part due to the reduction of colon cancer cases and the rising costs of modern colon cancer chemotherapy.  Yet, for the individual patient, the burden of suffering and death likewise fell dramatically. Furthermore, the more expensive upfront costs of percutaneous coronary intervention (PCI) with angioplasty and stent is more cost effective in long terms than the less expensive upfront costs of thrombolytic therapy.  In these instances, and many others, the best therapy turned out to be the cheapest and most cost effective by the reduction in disease burden and patient suffering.  

In all of this, the message from the ages is the truth that the best medicine is also the cheapest by prevention of disease burden, but I fear it is lost on the newest generation of practitioners who are taught to truncate their diagnostic and treatment protocols to only the most likely causes and the least expensive options.  It is a new mindset that flies in the face of the wisdom of men such as Sir William Osler, the father of modern internal medicine where the uncommon and rare hoof beats of the zebra were given credence with the considerations of the common.  

 Sir William Osler 1849-1919        

"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head."

I have diagnosed only one patient in my entire career with parvovirus when she presented with symptoms seemingly the same as the flu, yet different, I spent an extra few minutes reviewing the patients symptoms and ordered the test to confirm that it was parvovirus and not influenza.  The results in many ways were purely academic, since the treatment for both pathogens is supportive care, yet my training in the traditional practices of internal medicine lead me to investigate further. However, the patients son who presented to another physician with the same precise symptoms as her mother never knew of his parvovirus infection since his physician trained in the modern cost effective methods of diagnosing and treatment never considered this as a possible cause of his viral illness.  

There are times where looking for the needle in the haystack makes a difference for the patient and in secondary analysis early diagnosis is also cost effective.  It is time for the patients to learn of these new medical ethics to push their physicians to stay focussed on the wisdom of the ages past from Sir William Osler and those that established the practices of modern medicine in the first place.  Taking short cuts in any profession leads to the demise of that profession and medicine is not protected from that outcome.

HemoDoc, Doctor to Patient will explore the general issues of medicine today from both the perspective of a patient and a doctor with special focus on renal disease and its treatments since that is the malady I bear.  The "Hemo" part of my avatar is that of the hemodialysis that sustains my life and how the doctor in me is attenuated by the role of being a patient suffering from a disease with worse outcomes than many cancers.  It is not a role that I have chosen in life.  It is however a role that teaches me much about the need to always keep the patient and their individual needs at the forefront of all discussions on health care.  The Oath of Maimonides spoke of this unique relationship hundreds of years ago. May we always be humbled by it:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

Comments

[Matt Sparks]

Look forward to following. Great site. Will link to it on RFN.

[Peter Laird, MD]

Thanks Matt. I continue to read RFN daily and highly recommend it for patients and docs alike.

[roberta mikles]

Peter, this is fantastic and have sent the link to my many patient safety advocate contacts and organizations for them to distribute.

Roberta Mikles RN BA
Director, Advocates4QualitySafePatientCare
www.qualitysafepatientcare.com
San Diego, CA
858-675-1026

[MooseMom]

I love this blog!

MooseMom

[Peter Laird, MD]

Dear Moosemom, thanks for the kind comment. Please don't hesitate to let us know what topics and information that may be of help.

[MooseMom]

Hemodoc, I'd be quite interested to know more about the interaction between you and your nephrologist? What do you suppose it is like for your doctor to treat you, a fellow doctor?

[Peter Laird, MD]

Actually, my current nephrologist, Dr. Scott Rasgon, is the head of the nephrology program at Kaiser Sunset in LA. We have a very good relationship and he is open to my requests. He tells me I keep him on his toes. He is also an advocate of nocturnal dialysis and short daily. If all nephrologists would put the interest of the patient upfront and foremost, we wouldn't have the problems that we do today.

[MooseMom]

I've heard of Dr. Rasgon. You're a fortunate man. I know my neph supports NxStage, but we've not yet had that discussion. Usually I just want to flee his office, but one day I'm going to have to bite the bullet and tell him how I want to receive dialysis. I hope he'll be amenable to my requests. I don't fancy the notion of having to talk my own doc into allowing me to have the best treatment available. We're always told that we have to be our own best advocate, but not all docs make that easy to do.

[Peter Laird, MD]

Actually, I did discuss the issue with Dr. Rasgon and he was going to look into getting sterile disposable tweezers for his patients. I see him tomorrow morning for my monthly visit.

The key to getting the best out of any doctor is communication and bribing him of course simple little gifts at Christmas time. Truthfully, finding a truly altruistic nephrologist today is a chore. I am fortunate that my HMO is non-profit and that the nephrologist get no financial incentives for reducing care as do many that work in the for-profit world. I searched for a long time to find a good nephrologist who not only listens to his patients but genuinely cares how they do. That is the halmark of a good doctor, no matter what field they represent.

[Rod McDonald]

I really enjoy this blog and thank you for writing it. It addresses so many of the issues faced by home hemo patients. I was on PD for four years and by the end, I was a very, very sick man. I was sleeping sixteen to twenty hours a day. My energy level was low and I no longer enjoyed life.
There was a new program for home hemo set up in my health district and I phoned continually until I was accepted into it. I was their eighth patient. I have been using the Fresinus Home 2008, three nights on for eight hours, one night off. I am a double needle. My blood levels and general health have improved considerably. I am a convert. I, along with the other patients, there are fourteen of us now, detest going to the clinic for treatment. The staff are good to us but the culture of sitting in a ward with thirty six other patients is less than pleasant. At home, I choose the time to go on and off. My wife and my cat wander in to my bedroom to visit. I have my books, my computer and television. I enjoy taking responsibility for myself and my health. My only complaint is that I have never been able to sleep on home hemo. I can handle the light but the noise from The Millenium RO machine prohibits me from dropping off. Most nights, I read or lie there. The Nx Stage is not presently available in Canada or else I would take a look at that program. One of your articles addressed the expense of hemo in The USA. In my region, a patient on in centre costs a $100,000 per annum and a home patient is $50,000 per year. Considerably less than the American charges. One of the differences is that a law suit against a medical doctor is extremely rare in Canada and insurance is not the same issue as it is south of the border.
Your article on Stewart Mott's twirly bird method of cannulation really helped me out. I switched to that insertion method four months ago and so far, I have been one hundred percent successful.
Thank you.
Rod McDonald in Regina, Canada

[Peter Laird, MD]

Cost of medical care in the US is greatly inflated compared to the rest of the world. With the so called Affordable Care Act, they project an average family will pay $20,000 a year for health insurance alone. Things will only get worse here in the US not to speak of the impending physician shortage which will create huge waiting times. I am not happy with this situation at all. Looks like it is too late to reverse the damage done already. This will lead eventually to a single payor system which is not something I am looking forward to at all. Things will not get better in the US at all. Quite sad to see what is happening to health care here.

[Rod McDonald]

As the Nx Stage is not available in Canada yet, would you please tell me what the schedule of treatment is for most patients. Someone told me that it is three and half hours a treatment. Is that every day or are there days off? Also, is there a reverse osmosis water treatment machine as a part of the therapy or is the water handled by saline bags? Thanks.
Rod McDonald in Regina, Canada