American Medicine: Good at Acute Care But Lousy With Chronic Illness
I have had a couple of emergency room admissions as a patient; usually, I was out cold or damned close to it. Sometimes I think I was just in pain or so uncomfortable or so horrendous that I blocked out the memory entirely. Other people, people who seem to know something about medicine, did tell me about things that I did not remember.
Putting their accounts together with what I did check out or do remember, I am convinced that nothing wrong or horrible was ever done to me in an American emergency room. Not in my late teens and early twenties when I worked in an emergency room in downtown Boston, although many of the technologies we now take for granted were not
I have never been cared for in a French emergency room, except for the time the left half of my face and windpipe swelled up because of an acute allergy to some rare species of white celery that grows in France. I was taken to the emergency room because I felt quite ill indeed. But by the time I got there the symptoms had gone away. They delegated an advanced medical student (perhaps more accurately, a young intern) to talk to me and I was sent home with no treatment, except being told never to eat that rare kind of celery again, which I have not. I do, however remember that interview in some detail. I can tell you, from that interview as well as from my studies, that French doctors, and probably others who study in countries with similar systems, do not think the same way that American doctors do.
In medical school, with rare exceptions, all of the examinations (at least then) were essay questions. Prior to the examination, usually quite a bit prior, the student was given a list of all possible questions that could be asked on the examination. If all of the questions could be answered completely and accurately, then the course work had been learned. Oh, some students tried to make a science of what questions had been asked in past years, and did not learn the whole list. Sometimes they won the game; more often, they did not.
In the first couple of years, known as the “pre-clinical” ones, the question would be a region of the human anatomy, or a group of biochemically related compounds, or something that was a chapter heading and easily separated from the remainder of the course. All sources of information were fair play; textbooks, encyclopedias. I actually remember looking at Leonardo da Vinci’s anatomical notebooks when I was putting together the drawings I would have to produce from memory, as well as the descriptive text. To do it verbatim, most agreed, was a waste of energy. Some students worked together in groups, but nobody seemed overexcited to help the American who was viewed as serious competition. Besides, the most important thing to do was to get the class notes, because no matter what other sources were consulted, the most important thing seemed to be to reproduce as closely as possible what the professor had said in class.
In the later or “clinical” years, when one is actually learning how to take care of folks, the format of the questions (and the presence of long lists) changed a bit. Virtually every single question started with “Conduite a tenir devant….” which meant “Behavior to be followed in front of….” The ideal was for each one of us to construct a “Cerveau tiroir,” which roughly translates as “file-drawer mind.” It would totally eliminate the need for thinking when the patient’s life was in jeopardy and the physician’s stress level maxxed out. The preparation of the essay question went beyond the previous considerations of “encadrer” (“framing”) a question and making something elegant of it. It had to be practical. People seemed less worried about the use of outside sources, and far more worried about doing the correct thing in the correct hierarchical order. Although people still met for study sometimes, the accent was more on the personal aspect of question preparation. We were told in no uncertain terms that the preparation of these “Conduite a tenir devant” essays was the predictor of the quality of our practice. Most of us would end up either rural physicians or doctors “du quartier” (of a part of town, presumably in a large city, like Paris) and we would have to continuously be deciding how newly published and discovered information and/or invented procedures would change how we practice. We would redo our “conduite a tenir devant….” for as long as we were practicing.
I have never known anyone in America who has studied in this manner, before or since.
The “Conduite a tenir” was supposed to have been an infinite resource; and if it wasn’t, when you were in clinical practice, you built it until it was. Chronic conditions as well as acute were supposed to have been included in the “file drawer” of your mind. I am not stupid enough to think that everyone kept theirs up to date. Doctors are not saints. There were doctors blinded as pride, there as well as here. I remember hearing stories of socialite doctors who put on riding habits and went hunting with the mayor and the public notary (a person of some prestige in the French villages, even then) and they did all sorts of things, as the doctor was traditionally respected as one of the most educated people in the country village, and some of them would turn up in politics as that one did. Not that everybody was as visible as he, but people had different kinds of lives and probably did not all spend their lifetimes working on their files of chronic “conduite a tenir” stuff. Sometimes the continuing medical education sorts of materials had some neat “conduite a tenir” stuff, but there was no force anywhere to make you learn it or put it in your practice. People probably would not drop like flies if you did not obsessively update your “conduite a tenir.”
It was not until medical school that I met and dealt with female physicians. Sometimes they were quiet and obsessional and brilliant, really brilliant. I loved to talk to them about what their practice lives were like. About how some of them had managed to raise exemplary broods and to have been what seemed to me to be exemplary physicians. I collected their practical, clinical tips as one would collect semi-precious stones. The atmosphere of the University seemed somehow wildly protective of its own. I knew many already, who had seemingly overblown egos, who I did not think could have made it on their own outside. Sometimes, I learned later, they had tried and failed.
There were two women, curiously enough both of Vietnamese origin, whom I met during a rotation in obstetrics–gynecology. I worked in a laboratory then. Students (unless they were in the obstetrics gynecology residency) simply did not attend a great deal to clinical material. They did assist in prenatal examinations, but could not even watch deliveries. The idea of the chief of that illustrious department (who was far from personable and, in my humble opinion, not as brilliant as he considered himself) was that it was hard enough for obstetricians–gynecologists to build practices that they should not have to put up with competition from general physicians. This is the kind of thinking that has rendered specialties entities that are difficult to integrate; made them feeble. Keeping information secret. I cannot imagine a more primitive view of the profession; yet over the years, I have dealt with more and more doctors who have felt this way, and crippled patient care. The chief of the laboratory, which did everything from routine smears to oversee the sperm bank, was world class as a researcher more than a physician. She had been Nobel Prize class. She was working in an obstetrics-gynecology laboratory for the same reason that, many years later, the United States Army had ordered me to take care of ambulatory care medicine (read doing vaginal smears) for women. Because of that accident of the single moment when that uniquely chosen representative of Daddy’s highly rich and competent sperm pierced mother’s parsimoniously unique single celled ovum. Because of the accident that had us born female. Seems obvious now, but I was more idealistic, more in denial then. But then as now I was so thirsty for knowledge that a single remark coming from a single doctor could change my life.
The first Vietnamese female doctor was a brilliant and thorough clinician. She spoke at length with the women, more as if they were friends than as if they were patients, in the distant formal manner of the men. I gushed over her, for although I did not want to be an ob-gyn, I desperately wanted her level of knowledge, and her style. She would not tell me (as other transplants from Vietnam to France had) about her personal circumstances. She did tell me that women among her relatives had suffered trauma of many sorts, including traumatic pregnancies, that had made her want to do what she did. She had been correct. No other details were necessary. I asked her why she seemed to go into more details than other physicians I had “assisted” (more like watching and trying to remember). Then she told me something I can reproduce almost verbatim with translation.
Doing routine care is easy. Someday a computer can do that part. Most pregnant women have normal prenatal checks and normal children. You can put the “conduite a tenir” into a computer and mostly everything comes out right. But the job of a doctor, and it is very difficult, is to maintain a sensitive and knowing vigilance. You have got to find the one who is not right. You cannot let that slip by. The job of a doctor is knowing when the “conduite a tenir” does not work, and what to do.
The ring of truth sang through my body. I knew she was right.
The other Vietnamese obstetrician-gynecologist was, it went without saying, fully qualified in that specialty, and could have done prenatal exams and such, but she did not. She was fully qualified in acupuncture, something far rarer then than it is now. The particular niche which she had not sought but in which she found herself was providing treatment by means of acupuncture for women who were pregnant and for whom it had somehow been decided that western treatments were too dangerous. From benign situations such as morning sickness and back pain to the most exotic of cancers, there is no doubt that her treatment contributed to the birth of many healthy and happy babies.
The most amazing thing about her, to the wise directress of the clinic and to me (once I understood) was the way that her ability to deal with both the simple and the serious problems of pregnancy so artfully straddled and totally encompassed both the Western and Eastern way of looking at things, simultaneously. One minute she was talking estrogen and progesterone and trimesters, and sophisticated blood tests and within the same sentence it was yin and yang and meridians.
I asked her about it once. She shrugged her shoulders. “I do not care about theoretical constructs. I just care about what I have to do to help the patient.”
With a single sentence she had demolished every “conduite a tenir” in the field.
They were both clinically brilliant physicians. I have never denied that my life was saved by American emergency care. When I went into the emergency room not far from a coma, as far as I (perhaps the last person who could do it accurately) could reconstruct from the intelligent observations of others, there was never any “conduite a tenir.” My symptoms shifted wildly. Every time they did, the reasoning went from one symptom to another. It worked fine. American doctors at least in the emergency room can think quickly. American emergency room care may be the world’s best. Of course, how the emergency rooms are used in this health care system may have diluted the efficacy. Every emergency room known to me is overused, with waiting and triage being the dominant function. Like at wartime, only permanently and at home.
It is very possible that the European style “cerveau tiroir” could have worked slower or less efficiently on my past emergencies. Of course, the French use the emergency room less and put the doctor in the ambulance, so a lot of our emergencies are not emergencies at all.
I submit that for chronic care, as for most conditions in life that require thought, you need to have a “conduite a tenir” and know when to ignore or explode it.
The idea generalizes almost before you can apply it. I cannot count how many times I have told parents it is a far better idea to give children a strict education than it is to give them nothing at all. Assuming adult responsibilities in civilization seems to be deciding what to reject, and how, in any and all spheres. The apprentice mimics the mentor until he finds his own way.
Vigilance and knowing when to abandon the “conduite a tenir” is fun. It is being the vocal character in “The Emperor’s New Clothes.” It is being the hero when heroism is not expected. It is brilliance. It is the edge.
One overwhelming reason I got endorsement in a French medical school to be the first woman training in neurosurgery was something I did in a state mental hospital. Now this was an early clinical responsibility where nobody expected any clinical responsibility. I had, in my mind, pretty much rejected psychiatry as a “low power” specialty as I thought and still believe I have quite a nicely functional brain and can do a lot in this life.
We were expected simply to spend time with the patients, to learn not to treat them with laughter or disdain, and to practice doing physical exams on them as they relished any and all attention paid to them.
I was doing a neurological exam on a patient when I found a neurological deficit. I reported it up the line, as I thought he had a brain tumor and I thought I knew where. He went to neuro-surgical clinic and someone replicated my findings. I was suddenly the prodigy medical student for having reproduced what I had been taught. My real genius, I think now, is that I switched the “conduite a tenir.” He ended up having brain surgery; a benign tumor was removed. I doubt he was ever a high level anything, but I actually saw him a few years later in the neuro-surgical clinic, and found my old note in his chart, although nobody in neurosurgery remembered how clever I had once been. Nobody would have even thought of trying to measure if his life was any better. I suppose it is enough to say life is better outside of a state mental hospital than inside one. He had at least some of the simple human dignity he told me he had once craved.
Once you are outside an emergency facility in these United States, you are a capitation, a head count. Nobody thinks of you as a problem to solve. For example, I remember an outpatient clinic where I was called a “diabetes maintenance” patient. Because I was a doctor, they told me they would take good care of me. First, they took my blood sugar, which was admittedly more than a bit high back then. They had me wait for a young doctor in training. During that time I danced like crazy and lowered my blood sugar to normal limits. They rechecked it with disbelief. There were other things going on metabolically which they did not check and consequently, missed. They told me I needed to be followed regularly and ditch the ego that made me think I could care for myself. They said I could have any kind of doctor I wanted: “female, anything.” I asked for someone with experience in metabolic anomalies. They assigned me to the nearest Caucasian female, with no particular endocrine or metabolic experience either I or they could determine.
To keep things uniform, everyone in that clinic got the same tests at regular intervals and the same examination at regular intervals. Clearly, I was no emergency. They knew raised blood sugar could become an emergency, but I had already fixed that. It would not and could not occur to anyone in that clinic that my diagnosis was wrong. It goes without saying that I never returned to the clinic in that famous American university. This is why these United States cannot care for the chronically ill. If the population in general does not want to think, there is little we can do. We can’t be stuck in a “conduite a tenir” because American physicians do not appear to learn that way. They seem to learn to reason on the spot. You need to question before you can reason. You need to talk to the patient before you can question.
There is no time. Those trainees in that University clinic had no time. Nor did their supervisors. A computer could do a better job of “thinking” than a hurried doctor. The few clinics I know that use them would only think of them as ways to gather data. Doctors are supposed to think. It is possible they never learned how; or more likely, that they once did briefly but collapsed under the demands of time and money. Some who once loved the intellectual interaction with another human in the pretense of helping to make them well, at the relative leisure of a “chronic” situation in the office, well those “some” may at least know what they are missing. The younger doctors whose only option is a “job” when they finish training will never know.
The Obama plan won’t help. It addresses access, not quality. What good is access to care that keeps people sick? If physicians can start with a “conduite a tenir” then maybe they can know when it goes wrong.
I have one case that happened when I was in a public clinic that I shall never forget. I was playing “the Emperor’s New Clothes” again. A young man, frustrated by his lack of success in life, had been treated for a chronic and general anxiety disorder to no avail, He said that no medicines were any help but the side effects were “a bear” so he would rather not take anything. I urged him to accept some things he could at least take with him, in case he got “out of control,” and I begged him, over a few visits, to go for blood tests. A test of his thyroid function showed the latter to be very sick indeed, and he got appropriate treatment and medication and felt better. I informed him and everyone relevant in the clinic that he no longer required psychiatric treatment or medication. He had no complaints about his life; he had no symptoms at all. A couple of months later, another psychiatrist, older and fatherly, came to compliment me on my excellent care, said the patient said I had given him his life back. Maybe I should have been “nice,” but I really only had one question. “Why the hell is he still here?” My fatherly friend answered. “I just see him to make sure that he doesn’t need any psychiatric medicines.” I answered. “You’re kidding, right?” “Also he has a psychiatric history, so he sees his therapist.” The patient was being seen for Post Traumatic Stress Disorder according to the therapist, whom I had long since informed that the patient did not meet DSMIV criteria and should be terminated. This particular therapist kept patients for years for “support” and had dared tell me he needed to “support” the patient for his thyroid problems. The therapist, of course, had nothing resembling medical training and would not have recognized a (human) thyroid gland had he been struck in the face with one. The kindly and fatherly psychiatrist ran away, to avoid more questions.
I have only one question left. Why do we do such a good job keeping chronic patients ill? I can only infer it has something to do with money.