Every once in a while a topic comes up that takes me back to the origins of this blog. At its core, DrJohnM aims to merge the worlds of athletics, health and medicine. The glue, the secret sauce, is mastery of the obvious.
As an athlete and doctor, I get to see how both plans parallel each other.
Katie Compton is an American cyclocross champion. She dominates her races, both in the US and Europe. I have seen her race on many occasions and her prowess is more impressive when viewed in real-time as a spectator.
A friend sent me a list of Ms Compton’s most valuable nuggets of coaching advice. They highlight basic precepts of Medical practice.
Less is more: This has become the mantra of modern-day medical practice. Nearly every week, a study comes out touting the values of a less-is-more strategy. In Medicine, we seek smarter, not more, therapy. Catheter ablation of atrial fibrillation has evolved to burn less, not more. Programming of ICDs aims to shock and pace less, not more. The list goes on.
No sense beating a dead horse: Doctor-surgeon-writer Atul Gawande authored this important piece on the frequency of surgery in the last year of life. Nearly 1 in 3 elderly patients undergo in-patient surgery in the last year of their life and almost 10% have surgery in the last week of life. The intensity and amount of care that is delivered as patients near end-of-life is a huge problem in US healthcare. It’s not just a crisis of cost; it’s a crisis of humanity.
All doctors, and I guess most patients, know this. Sadly though, un-nuanced sensational talk of death panels has inhibited the conversation. The solution here is simple and obvious: at all levels, patients, doctors and policy makers, call them stakeholders if you must, need to earnestly discuss goals of care. What are the patient’s goals? Has anyone asked? Has the truth been told?
Same as we always do; don’t mess it up: This one relates well to the electrophysiology lab. Over a decade and half, we have developed a repetitive plan. The team knows it; the doctor knows it, and it works. We have years of good results to show for it. Outsiders have studied it and they too validate the process. We try not to deviate from what works. Sure, new technologies come and we keep an open mind to them, but the basic plan stays the same.
As an aside, I think this tenet is why many doctors are disturbed by the forced adaptation of electronic medical records. During our initiation of EMR months ago, a flustered colleague remarked that it would be a bad time to be a sick patient. It’s because the un-Apple-like health EMR system had caregivers off the plan that works. It’s better now, but still, EMR in its current form ‘messes up’ what has worked for centuries—human-to-human time with the patient.
A good coach takes a great athlete and doesn’t screw them up: There are rules in medicine: You can’t make an asymptomatic person feel better. Do no harm. This is at the heart of the debate on screening and doing things to people without symptoms. In the world of heart rhythm medicine, this rule comes up frequently: how much burden should we ask a well-patient to accept in the form of therapy for something that hasn’t happened yet. Think implanting an ICD in a patient without arrhythmia or treating a patient with asymptomatic atrial fibrillation with a potent medication. These are important issues to think about. Don’t screw up the patient. Do no harm. Sometimes the right answer is to treat; but not always.
Just some things to think about.
JMM
2 replies on “Good coaching is good doctoring…”
Nice post, John. Re: the end-of-life issue, terminal patients at Mass General Hospital who were shown a video of what their final days would be like in an ICU unanimously rejected aggressive end-of-life care. Why couldn’t this be made mandatory for all such patients so they can better visualize what dying this way looks like? Then, of course, their providers would still have to honor their wishes, which also doesn’t always occur.
Wow! Strong words from a cardiologist. Less is more? I totally believe it, but I didn’t thing there were many specialists out there who do. As an anesthesiologist (and avid spinner), I see those end-of-life surgical procedures every day. I always turn to the nurse in the room and say “please don’t do this to me.” As to asymptomatic patients, I always tell my parents and their friends “the quickest way to get diagnosed with something is to go to a doctor” and “all testing leads to more testing”. Sometimes the “care”, while well-intentioned, is worse than the disease, or the non-disease as the case may be.