Poisoned by a Doctor! (And other Accusations)

“You doctors just want to give me poison and I am not going to take it!” I have been accused of many things in my 20 years of practice but intentional poisoning was something new and the patient's words surprisingly harsh. He was angry from the moment I walked into the room. He was first offended when I questioned his reasons for not taking the medications his cardiologist had prescribed. He had experienced some slight swelling of his legs, decided that this side effect was too severe and made the decision on his own that the medication was unsafe. He was convinced that the doctor had put his health in danger and that I wanted to do the same.

When I explained that this was a relatively common side effect with this medication he became angry. “Why would you prescribe a medication when you know there are side effects?” He was nearly shouting and his faith was contorted in anger. He was MAD!

“Because it is an effective drug and the side effects only happen ten percent of the time!” Was my reply.

He would have none of it. It was his opinion that no doctor should ever prescribe any medication if there were any side effects. I tried to explain to him the nature of side effects and how they were outweighed by the benefits of treatment. I spent the next 20 minutes trying to explain to him the nature of heart failure and why medicines were crucial for his health. I explained how the medications worked and why the side effects were reversible or manageable. He argued with me every assertion I made. He told me that doctors were dishonest people who cared more about money than they did people, unscrupulous individuals who would just as soon poison someone as treat them.

I finally gave up. As calmly as I could I told him that if he was going to refuse care for his heart failure that I would not be his doctor. If he didn't trust me it would be impossible for our relationship to continue. I explained that my preference would be for him to remain a patient and be healthy but that remaining a patient and being healthy would mean following my instructions. He continued to argue with me so I opened the exam room door and gestured for him to leave. “You will need to find another doctor,” I told him, and sent him on his way.

After he left I composed a letter summing up what had happened (detailed documentation is required when a patient is dismissed) and put it in the mail. I reviewed our conversation and concluded  by saying,

“You made it clear that you do not trust doctors, myself included. The physician/patient relationship has trust as its foundation. Your good health and medical treatment is dependent on you following expert medical advice. Our lengthy conversation today proved to me that you are unwilling to do this.

If you wish to remain a patient in my practice, you will need to accept and follow my recommendations, and schedule appropriate follow up visits. If you are willing to follow my recommendations and respect my judgment and opinions, please schedule a visit to move forward with your care.

If you plan on continuing to argue with my recommendations and refuse to comply with treatment plans, I must insist that you seek care elsewhere.”

I had my staff send the letter via certified mail, convinced that I would never see him again. Which is why I was so taken aback when I saw his name on the schedule 5 weeks later. I entered the room cautiously, prepared for another conflict.

It never came. He was incredibly apologetic from the outset. I asked him what changed his mind. He told me it was the letter! He realized that I was serious about his health and decided right then that he didn’t want to see anyone else. 

His dramatic change of heart was something else I had not seen in 20 years of practice. I was truly impressed with his humility and told him so. We agreed on a new medication plan for his heart and blood pressure and arranged a follow up visit. It was a very pleasant encounter.

It was also educational. He taught me that people can change, even those who seem intractable and unreasonable. He reminded me of the power of forgiveness and the beauty of a fresh start. I am actually looking forward to our next visit.

- Bart 

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Super Bugs. A Super Big Problem.

Doctors have been warned about it for decades. If we did not stop over-prescribing antibiotics the day would come when antibiotics would not work anymore. Some of us listened, many of us didn’t and society is about to pay the price. There has been an outbreak of a nearly unkillable bacteria at UCLA Medical Center.  

The long tubes called endoscopes that are threaded down the throat and into the upper intestinal tract for certain procedures became contaminated with a particularly nasty strain of a common bacteria, one that is resistant to the most potent antibiotics. As a result of the contamination over 150 patients were exposed and a number have died. Even if this were the first outbreak of a resistant strain of bacteria there would a cause for worry.

It is not the first outbreak and there is reason to be seriously concerned. Common infections have been growing increasingly resistant to antibiotics for decades.

Staphylococcus Aureus is a common bacteria that can be found on the skin of 25-50% of healthy individuals. It is the most common cause of skin infections and can cause severe illness when it enters the blood stream. Originally sensitive to penicillin, resistant strains were discovered within just years of the antibiotic's first use in World War II. By the 1970’s penicillin was no longer effective at all.

As newer forms of antibiotics were effective against Staph there was not widespread concern. Methicillin was a readily available and relatively inexpensive alternative, and it was effective. Resistance to Methicillin was known but it was rare. Methicillin Resistant Staph Aureus (MRSA), was found in only 5-10% of hospital and nursing home infections and was almost never seen in the community. Things changed in the late 1990’s. The incidence of MRSA exploded, up to 50% of Staph infections were resistant in many hospitals. 

Within just a few years MRSA was no longer just a hospital problem. It spread into the community and healthy people began to develop severe skin infections and abscesses. I witnessed the epidemic in my practice. Prior to 2001 I treated 1-2 skin abscesses a year in the office. By 2010 I was treating 1-2 abscesses a week. The bacteria had not only become widely resistant it had become much more aggressive! Hospitals have now been forced to develop new screening and isolation procedures to prevent staff members from inadvertently spreading the disease. The world has changed forever.

The problem of resistance is not limited to rare infections. E. Coli is the bacteria responsible for the majority of urinary infections. When I was an intern in 1990, in the hospital in which I worked  ampicillin was effective against E.Coli 72% of the time and cefazolin was effective 90% of the time. Just 23 years later, UCLA (just a few miles away from where I trained), reported that ampicillin was effective only 32% of the time and cefazolin in only 68% of cases. The trend is discouraging. If something doesn’t change we may run out of effective antibiotics in our lifetimes! How does this happen?

A study I read several years ago helped answer the question. Researchers in Israel cultured all of the children in a daycare. None of them tested positive for resistant strep bacteria. One child was treated with antibiotics for strep. A few weeks later the researchers tested all of the children again. 40% of the children tested positive for resistant bacteria! Antibiotic resistance was contagious!

When a person takes an antibiotic all of the bacteria sensitive to the antibiotic die. The only bacteria left are the resistant ones. Through a variety of mechanisms one bacteria can pass its resistance on to another one, so harmless resistant bacteria can pass resistance on to harmful ones. When these resistant bacteria are passed from one person to the next the resistance spreads through the community.

In smaller “communities” such as hospitals where antibiotics are widespread the danger of passing resistance is much greater, which is why this is where outbreaks often begin. The MRSA story reminds us that hospital resistance may not stay in the hospital, and the E. Coli story reminds us that resistance is not just a hospital problem.

Since the problem of resistance and overprescribing antibiotics is well known the question arises, “Why do doctors keep writing needless antibiotic prescriptions?” The answer is simple. Patients want them and doctors are afraid to say “No.”

I deal with this issue almost every day. Patients come in with an obvious viral illness and argue when I say antibiotics are not indicated. Science, studies, statistics and the stories of antibiotic resistance do not matter to these patients. They “know their body”, “just can’t afford to be sick right now”, “want to nip this in the bud before it gets worse” or “have a friend who had this and he took antibiotics and was better in 2 days.” I often am left with a choice. Do the right thing and have them leave disappointed or angry (and maybe not come back) or do the wrong thing and have them leave happy.

The choice is difficult enough to begin with but is compounded by the reality that doctors today are judged according to patient satisfaction surveys and are reviewed on Yelp. One unhappy patient with a grudge can cost a doctor thousands of dollars in bonuses and business. Because of this the problem will never be corrected by doctors alone. Patients need to get involved.

Patients need to educate themselves and others about the dangers of antibiotic overuse. (They can start by sharing this post!) We all need to learn to allow minor illnesses to run their course and to reserve antibiotics for those rare circumstances when there is no other choice. The world is changing and we are faced with a harsh choice. Do we want to treat our sinus congestion today, or do we want to survive our pneumonia tomorrow? It appears we cannot do both.

-          Bart

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References-

http://www.pathnet.medsch.ucla.edu/department/cliniclab/microbio/amic.pdf     http://newswise.com/articles/day-care-centers-spread-antibiotic-resistant-bacteria http://wwwnc.cdc.gov/eid/article/7/2/70-0178_article

After the Oscars, Recognizing the Real Winners

Normal people don't win Academy Awards. Normal people don't get nominated or get to attend the ceremony. Most normal people go through life without recognition or honor. They wake up each day and go about their business, doing what they need to do and have to do, playing their part in the theater of life in the roles they have been assigned. Mothers and fathers, craftsmen and laborers, managers and employees, all are essential and few are recognized. Watching the Oscars caused me to stop for a moment and consider some of those in my life whose performances in the last year have been truly remarkable. Here are some of my award winners for the last year-

Best Doctor in a Starring Role- Ehab Mady, a specialist in Vascular Medicine. Over and over again he has made the difficult diagnosis and gone the extra mile, providing stellar service and amazing care, even when payment wasn’t guaranteed. He is truly a life saver. .

Best Pastor in a Supporting Role- John Coulombe, the hardest working pastor I know. As the primary pastor to the senior adults in a church of thousands he is always in demand, performing funerals and comforting the grieving, organizing events and developing ministries. He speaks several times a month, tirelessly advocates for the church to be truly intergenerational and still finds the time to be a source of encouragement to me. He never seeks the limelight but his light shines.

Best Produce- Mr. W,  Patient who runs his own construction company while battling chronic and severe pain from a severely damaged ankle, prostate cancer and a heart condition. In his extra time he leads a Bible study, and he never complains. Each time I see him he manages to encourage me. 

Best Director- Peter Mackler, the Executive Director for Government Relations for Memorial Care. He puts in long hours and countless miles, traveling to Washington DC and Sacramento advocating on behalf of doctors and patients, most of whom will never know how hard he has worked for them. I have seen in him action and benefited from his counsel.

Best Special Effects- The Parents in my practice with special needs children who juggle work schedules, school conferences, and doctor’s appointments, the spouses holding the family together while their husbands and wives battle serious illness, the countless people who each day put one foot in front of the other and simply get it done. They challenge and inspire me.

As I consider all of these people I am reminded that the true stars in this life are not the ones up on the screen, behind the podium or on a stage. The true stars are more likely to be in the audience or behind the scenes.

- Bart

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Home Births, Hospital Deaths

By the time she arrived at the Emergency Room she had already lost a lot of blood. She was rapidly transferred from the ambulance to an ER bed and within a matter of minutes the life-saving transfusion was started. Had she waited just minutes longer to call for help she may not have survived. Her new baby would have been motherless.

For the doctors in the emergency room the treatment was common, a matter of routine. The reason for her brush with death was not. Post-partum hemorrhages are usually handled on the maternity floor, not in the emergency room. If her baby had been delivered in the maternity floor the bleeding would have been handled faster and the transfusion averted. Unfortunately she had chosen to avoid the maternity floor and have her baby at home. Her decision almost cost her life.

It was a decision that I had repeatedly and strongly argued against. I was her doctor for the first 4 months of her pregnancy. She had made it clear that she wanted a “natural” experience and I had promised her that this could be done in the hospital. I understood that many women preferred a natural delivery and had extensive experience managing natural childbirth. I was confident that her wishes could be honored and promised her they would. When she made the decision to deliver at home I had to resist and released her from my care. From my perspective as a doctor and as a father choosing home birth was and is one of the most selfish choices a woman can make.

Home birth goes against the two values that define obstetrical practice- Protect the health of the mom. Protect the health of the baby. These values guide all obstetrical care. The maternity unit is the only place in the hospital where the health care team begins with healthy patients and then works to keep them that way, so bad outcomes are especially tragic. Everything done by the nurses and doctors is directed at early identification of problems and preventing complications. The only acceptable outcome is a healthy mom and a healthy baby and no action or decision that makes that outcome less likely is tolerated.

While the goal of healthy mom and healthy baby is non-negotiable there is plenty of room for maternal choice during the course of labor and delivery. Birth positions (sitting, squatting, lying down), analgesia choices (epidural, narcotic or none at all), eating during labor, avoidance of IV lines and episiotomies, early nursing and skin to skin contact were all a part of births I attended. I often bent over backwards to meet the mother’s needs even if it meant spending extra hours in the hospital. My willingness to honor maternal wishes had one limit- I would not do anything that put the baby at risk. This is why I opposed home delivery.

In spite of opposition from the medical profession home birth seems to be making a comeback. While there are many possible explanations for the trend the facts support the conclusion that the choice to deliver at home is less about love and health and more about personal feelings and selfishness.

The patient who nearly died of a hemorrhage gave reasons for desiring a home delivery that were typical. She wanted a natural delivery and the experience of delivering at home in a supportive and comfortable environment. These desires seem worthy but they are not, for both place the feelings of the mother ahead of the health of the baby. Babies have no recollection of the room in which they are born, do not grow up feeling more loved and desired because the lights were low and the bed was soft. The baby does not care. Home deliveries are all about what the mother wants and not about what is best for the child. Is this not the very definition of selfishness?

The argument against home delivery is simple. It needlessly places the baby’s life at risk. While the risk is not massive (life threatening complications are rare in most pregnancies) the risk is always present. The American College of Ob-Gyn estimates that newborn mortality in home births is triple that of babies born in a hospital. Why would a loving mother make a choice that needlessly increased the chance that harm would come to her child? What warm feeling or joyous experience can justify that risk?

Current research suggests that as many of one in three women attempting home delivery will need urgent transport to a hospital due to a complication in labor. The transfer rate is lower for women who have previously delivered vaginally but it is still significant. Like every physician who has practiced obstetrics for any length of time I can share a number of stories where being in a hospital delivery room saved the life of a mom or baby.

Consider this analogy- If a young mom announced that she was foregoing the use of an infant car seat because she wanted the child to be in her lap while she drove she would be reported to the authorities. Her arguments that it made her feel close to her child, that bonding was important and that the risk of accident was low would fall on deaf ears. It would not matter that she was a safe driver and that because of cell phones medical help was never more than a few minutes away. Everyone would agree that it was irresponsible and selfish to risk the life of her child in such a way. How is this different than choosing to deliver a baby at home?

I have heard that home birth is gaining in popularity, part of the recycled fad of interest in all things “natural.” I doubt this post will change the minds of those who do not trust the knowledge or intentions of the medical profession but there is one thing of which I am certain. When it comes to the place of birth the baby does not care about the experience. No one remembers their birth experience.

Everyone remembers when a baby dies.

-          Bart

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It's a Zit Emergency!

“My son needs see the doctor about his acne, TOMORROW!” The receptionist was caught off guard and unsure how to respond. While it is our policy to always see patients who have an urgent she was pretty sure that there was no such thing as a zit emergency. The call came on a Thursday afternoon and we were booked solid on Friday so she decided not to work the patient in. She took a message and told him we would call him back later.

At the end of the day they brought the message to my attention. It seemed a little absurd and unreasonable to the staff that someone could expect to be seen last minute for pimples. I almost never turn a patient away but they let me know this was not a time to go soft.  They told me that I spoil my patients and do not say “No” enough and they made it clear that this was a time when I should put my foot down.

“This is ridiculous!” they said, “they should have planned ahead of time. It is not your responsibility to bail them out because they forgot!” The rant lasted a few minutes/

They were right on every count. It was absurd and unreasonable. No doctor could reasonably be expected to squeeze in a last minute pimple appointment. (Pun intended!) They should have planned in advance and it was not my responsibility that they hadn't. I had every right to deny the request and no one could tell me I was wrong if I did.

But the thought came to me, “Is it only about being in the right?”

I thought about my Christian faith, which teaches that all people have gone astray and turned against God’s plan, and that we are all deserving of punishment. I thought that God could have looked at me and said, “You are going to hell!” and He would have been RIGHT. But God didn’t do that. He looked at me in my ridiculous stupidity and wrongness and decided that instead of punishing me, He would send His Son instead. He overlooked my wrongness and went above and beyond to help me.

With that in mind I told my staff that while we could turn the patient away and be “right”, overlooking their wrongness would only add 15 minutes to my workday. So together we all agreed that we were right and the patient was wrong, but that we would see the patient anyway, because that is how we would want to be treated.

We saw the patient the next day and I refilled the acne medication. I do not think that he appreciated or understood that he was being done a favor or that a special allowance had been made. That was okay. For me, the reminder that it is not always about being right was its own reward.

-          Bart

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