Intercepting the Asinine

My New England Journal of Medicine still arrives each week.  I pay for the subscription so I feel obligated to read two articles from it each week, roughly 100/yr, even in retirement.  They tend to be cases of the week or a review of something related to endocrinology, but I am as interested in the changes of how we practice, having lived through it.  One element that exploded during my final years as a clinician has been the number of directives and processes that differ from what an experienced physician would likely devise on his own.  Now, I may have gotten in on the ground floor of this, starting my post-residency career as a VA physician.  These guys didn't have the insight to allow me to receive a flu vaccine in my non-dominant shoulder.  One kabooby from the lab ordered, who didn't know what a patient looked like prior to autopsy, ordered that all the lab slips be placed in the chart without having been seen by the ordering doctor first, where they ended up in somewhat random order.  They used to transport World War I veterans 100 miles each way for their appointments, paying $700 dollars to the driver of a Ford Pinto that just squeaked by state inspection.  I had the transportation director price the cost  of a limo for the same trip.  For one-third of that, the old warrior could have travelled the breadth of New Jersey in style.  He would have to pay for what he took from the back seat bar, but if he drank too much, the VA would dry him out for free and hire the Pinto back to take him home.

On graduation to the university and private sectors, directives declined in number.  I am pretty hard pressed to come up with anything that matched the VA encounters.  Scheduling made sense.  Rules on charting were understandable.  We got our own parking spaces and as security became more important, ID tags enabled access to the places we needed to be to provide patient care.

And then came HITECH and the computer.  It all changed.  In an inner city area, it was common for patients not to keep appointments.  Any number of schemes were devised to either reduce the no-show rate or compensate for it, with scheduling bedlam when everyone came.  There was a directive to see everyone within seven days of discharge.  A schedule does not expand indefinitely, not everyone really needs to be seen sooner that three months by the consultant, and thinking about appropriate post-hospitalization is part of the competence that the residents are expected to acquire.  Meetings to discuss quality addressed non-problems to the neglect of what really needed more attention.

Intercepting the asinine seemed hopeless in this era of an expanded middle layer of managers charged with doing things that they don't really have the insight to do because they seemed like a good idea at the time.  Once there, they have a life of their own until the hospital is forced to reconsider by either legal allegations or loss of revenue.

It came as a welcome though unexpected surprise to learn that all elements of the inane did not have to become immortal.  A NEJM Sounding Board essay described an algorithm that can be computerized to identify and intercept the dysfunction, though not until it has become dysfunctional.

https://www.nejm.org/doi/full/10.1056/NEJMsb1900856

Based on importance, these mavens at NYU targeted processes that had no real basis but were intended to solve a problem.  If they didn't solve the problem, they were identified and sent back for rethinking.

Do we really need a computer algorithm for that or would a simple anonymous suggestion/complaint box suffice?  The big corporations probably addressed this decades ago.  A directive would come by or a customer would complain.  The VP's would hire people to address the concerns or deal with an external regulation.  Before you know it, you had people with significant salaries tweaking what would be better neglected.  Somewhere around the time of the 1992 election, they figured this out and pink slipped the capable high salaried people whose work wasn't worth doing.  Medicine has always lagged behind, which is why we are now being pummeled by insurers and product manufacturers.  They had their restructuring.  We have not.  If the algorithm really intercepts the many asinine processes imposed upon us, we might have a chance of catching up.

The Zipe

One who learns from his fellow…a single law…must treat him with respect. For so we find with David, king of Israel, who did not learn anything from Achitofel except for two things alone, yet he called him his "master," his "guide" and his "intimate"… (Ethics of Our Fathers, ch.6:3)

For some unknown prompting, maybe in response to current events, my mind gravitated one recent day to my esteemed neurology teacher, known to us as The Zipe, an abbreviation of his real name.  He passed away in early 2018, after a very distinguished career with a substantial obituary in the Boston Globe imported to legacy.com.  I would have remained unaware of this had is impact on me not transferred from the storage neurons to the more frontal ones.  At the time of my residency, The Zipe was in his prime professional years, approximately age 50.  He had been a veteran, a few years junior to my father.  The obit was not clear if the military preceded or followed his medical school years.  Capable neurologists were readily available but capable and colorful seemed in shorter supply.  In a Catholic environment, he was recognizably Jewish, a member of my synagogue not far from the hospital.  



Two stories stand out.  On a neurology rotation at Boston's main VA Center, The Zipe had been assigned ward attending.  We had a big group, headed by our senior resident, a somewhat compulsively thorough Radcliffe College/ Hopkins Med alumna with a childhood origin from a different stratum than the Zipe or me.  I was one of the junior residents and I think we had interns and I know we had at least one student.  Teaching rounds were conducted in a conference room rather than at the bedside, which the senior resident could handle very capably herself.  At one session, The Zipe wanted to demonstrate deep tendon reflexes to the group.  At the time, and maybe even now, neurologists were the last specialty to carry the classic black leather bag.  I had one too, a bulk purchase by my second year medical class.  They needed various equipment, from a reflex hammer, to visual cards, prescription blanks, a variety of tuning forks to test hearing and vibratory sensation, something to test olfaction, typically a vial of coffee, maybe a hat pin to test sharpness with the point and peripheral vision with the mother-of-pearl head.  The reflex hammer was usually not the rubber tomahawk that residents kept in their pockets but a more sophisticated torus with a weighted rubber edge held by a long plastic handle that had a pencil type point at the end to test sensation.  Too big for a pocket.  

Since The Zipe needed this reflex hammer, in the fashion of the 1970's he barked to the medical student:  "Hey Student, gimme my reflex hammer from my bag."  On lifting it off the table to get it, the student noted that The Zipe's black bag was a lot heavier than his.  He opened it, reached inside, and blanched with an "Oh My God."  Instead of pulling out the tool The Zipe asked for, he extracted a rather heavy pistol.  There's always one resident wag who asked whether this unexpected equipment was intended to test hearing or pain sensation.  The Zipe asked the student what was next to the gun in the black bag.  He pulled out a prescription pad.  The pistol was to protect those papers which even unsigned had street value and whose presence made the carrier, in this case the doctors, vulnerable.  The reflex hammer was also in the bag and retrieved next.  Our lesson proceeded. I have never felt any inclination to carry a weapon to protect my person or possessions in my professional capacity, but over the years, whenever an attack on a physician made the news, I wondered if The Zipe would have prevailed if he were the intended target.

His more enduring impact on me, one that likely made me think of him again, occurred at bedside rounds.  A consult had come in to assess a man who had been prematurely losing his mental acuity.  As students we are taught the elements of an orderly mental status exam and carry one out at least informally on all the patients we see in the hospital from then on.  People are usually obviously able to provide a history and converse normally or are obviously demented so the checklist of 

1. Judgment
2. Orientation
3. Memory
4. Affect
5. Knowledge
6. Attention span
7. Insight

tabulates quickly and informally.  When not obvious, there is a process for sorting this out.  The Zipe took us to the bedside to see if this veteran was prematurely demented.  He could carry on a fluent conversation, had little understanding of why he was being evaluated and knew he was in the hospital.  As was common among VA patients, and Boston citizens in general, he consumed a fair amount of alcohol.  Patients are asked the day of the week, who the President is, what the weather was like yesterday, where they served in the army which would reflect remote memory, and to start from 100 and count backward by 7's.  This fellow was a little iffy on some of the responses.  When asked the name of the President, though, he responded that he avoided politics, which were a lot less toxic then than they are now.

The Zipe completed his assessment, already done by one of the residents the day before, then back to the conference room for discussion.  Since this affable patient could get by until his deficit was exposed, the discussion involved what is and is not a true deficit.  People are just expected to know who occupies the White House as an unavoidable part of being immersed in a seeing and hearing environment in America.  People are expected to be able to subtract 7 from 100 irrespective of their education.  Even somebody who makes their living as a bank robber understands thou shalt not steal, but consciously selects to violate this.  Insight and acquisition of knowledge along with its retention are what make us a durable species.

In our contemporary environment, two generations of neurologists beyond The Zipe, people are a little uneasy with the various public presentations and rationalizations for the very reasons The Zipe tried to teach.  There is something fundamentally wrong about caging people along the border and separating children from adults.  Rationalize it any which way, it violates the CNS evolution of knowledge and insight.  Denying ethnic targeting when any observer can recognize it, something very common through American and World History, falls below the mental expectation that The Zipe, or me as his medical descendant, would have for normal CNS function.  These realities either did not exist or were dormant when The Zipe presided in his conference room.  Realities change, core principles of how a brain should be able to reason do not.

Very few teachers shaped my reasoning skills more than The Zipe, which is probably why my mind automatically migrated back to that indelible imprint just as valid today as when I sat in his conference room or a few rows from him at synagogue.