Thursday, February 26, 2015

Last week

Requisite Mona Lisa
sighting at the Louvre
I spent this past weekend in Paris with the same friends from the weekend before in Amsterdam. What a beautiful city! It was great to see the Eiffel tower during the night. Because it is so tall, you can see it from so many parts of the city; it serves as a great backdrop. While a couple days in Paris is not enough, I'm glad we were able to see the main tourist attractions as well as a few others. I think you could spend a weekend just seeing the Louvre.

Bridge over the Seine river with the Louvre backdrop
A beautiful sight anywhere in the city

This last week went by faster than I thought partly because I knew it was the last week and because I was busy both inside and outside of the hospital. Dr. Basto kindly invited me to his house for dinner. I had a wonderful time meeting his wife and children. His wife cooked an amazing dinner along with several desserts!

Observations from this final week:
Serghei, a medicine intern, and his wife, Olga, hosting me for dinner
-One of our patients has gradually become less tolerant of dialysis and had hypotension with systolics in the 70s. After discussing with nephrology regarding management, it was decided to reduce the frequency of dialysis. We started morphine as well for comfort due to some respiratory difficulty. One of the topics of discussion was what to do if the patient stops breathing. Do we resuscitate? For me, I wanted to know if there was a DNR/DNI order in place. However, it was not so simple with these patients. Discussing the issue was slightly unnerving giving that, as physicians and medical students, we are trained to focus on disease treatment, but now were looking at end-of-life issues. Interestingly, this topic is one that we've had for several of the patients on our floor, some more pressing than others. While we as physicians do need to make tough decisions, these ethical dilemmas can often convey a greater sense of power and responsibility to deal. The one challenge that comes with this is that physicians, as all humans, are unique and influenced by past and current experiences. Thus, each physician, if given such responsibility, might act differently according to his/her belief/experience structure. This coupled with the fact that end-of-life issues are fraught with uncertainty makes this an even more difficult issue. In other words, physicians left alone to decide the fate of patients might do drastically different things for the same patient. If I had an elderly relative I was caring for, would I want a physician who was risk-averse or risk-seeking? One that focuses on palliative care or one that pushes for resuscitation? Here I think it is important to have a structure or governing body help physicians with these difficult choices and one where lawyers can come in handy to navigate power of attorney and legal ramifications of decisions by patients, patients' families, and physicians. Last week I discussed the cost of health care. Here, again, cost is an important player in end-of-life issues. Resource allocation, I've noticed, is constantly on the back of people's minds. Should be push more for this in the US? Educating patients and their families about realistic expectations of resuscitation and care can be very important and seems to me should be an increasing focus back home. Even though it might introduce more policy, guidelines are necessary to help all parties navigate the issue.
Serghei and I on the famous Dom Luiz bridge overlooking Porto below

Dr. Basto and his family hosting me for dinner
Port wine, nata, and other desserts
made by Mrs. Basto!
-The night I went to Dr. Basto's house for dinner, I met him at his private outpatient office. It was a beautiful, modern building with all the latest equipment and subspecialty outpatient care for patients. Dr. Basto also gave me a quick tour of the private hospital. Comparing the two, it is clear that the money is in private enterprise. As we discussed, some private hospitals, such as the one we visited, are now able to do just about anything that public, teaching hospitals can do. For me, this raised the question: what can be done to keep residents at the teaching hospitals after they finish their residency? Currently, many physicians have dual roles: one in private practice and other in a public, teaching hospital. However, there are some shifting to just private practice. In the US, NIH funding, endowments, and established, wide-reaching infrastructure has kept the research and innovation aspect at teaching hospitals. There is some research being done at big private hospitals, but still the guidelines come out of academic institutions. It is interesting to see how much this public-private balance and money influences the work being done. For now, the public teaching hospitals still manage the teaching and research and see complex cases. However, only time will tell about the shift. I wonder what impact this will have on health care costs for the country as well.

-I had the chance to see the stroke unit this week as a friend and colleague of Dr. Basto's helps run it. We got to talking about the "fast-track" system set up at Sao Joao along with other hospitals in the area. Basically, once a stroke comes it, the team is immediately called allowing them to see the patient, review imaging, and come up with a diagnostic plan within the allotted time for thrombolytic administration if needed. The stroke unit at Sao Joao consists of internists and a neurologist. Given the structure of the "fast-track" system, it is clear how it can be replicated at other hospitals and objectively assessed for compliance. This brings up the issue of regulation vs autonomy. As physicians, we train in order to have the knowledge to assess each situation and make a thoughtful decision. However, a "fast-track" system is, in essence, evidence-based regulation regarding stroke management. Physicians do have some autonomy, but it is within the framework and guidelines written. If I had to choose, I would argue for more structure with some sacrifice on autonomy if this can yield better patient care in the long-run. Per Atul Gawande, a checklist might force a surgeon to review items he believes he covered, but it allows for a systematic approach reducing medical error. I think the worry is that physicians will no longer have the freedom to think through patient management and instead simply be following one guideline after another. However, I think there will always be further research and innovation on these guidelines and patients will still need personalized care. The area where a "fast-track" system for stroke or other overarching guidelines can help is in rural parts of a country that might not have as many physicians nor the resources in place. These guidelines allow for systematic improvement in whatever the disease focus.

Porto at night
As I wrap up my blog, I wanted to say I had a wonderful time in Porto and at the hospital learning about the health care system and issues that arise as it undergoes changes. Also, thanks to Dr. Basto for being such a welcoming host!

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