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Perspectives on Practice Physician-to-physician perspectives on the evolving practice of medicine. July 2018 Dear Reader, It’s summer, when fourth-year medical students graduate and start their clinical training. I still remem- ber making my own first rounds as an intern. Although it is clearer with the lens of hindsight, we are all in this together — learning from our patients, from each other, and from trusted sources of medical knowledge. None of us ever stops learning. Since its inception, NEJM.org has been providing the information and experiences that readers like you need to keep up with the latest advances in medicine and translate evidence into practice. What you might not know is that we also publish what we call Perspective articles on issues that affect medicine and health care — matters that invariably touch us all. In this collection of Perspective articles, we’ve gathered compelling personal narratives written by physicians that explore the experiences of their practice. In one, a doctor describes her concern that a reluctance to prescribe opioids may be keeping her hospice patients needlessly in pain. In another, a physician shares her dilemma of needing to see more patients, but also wanting to build deeper relationships with those patients. These are just two examples of the stories that are to follow. We hope that you enjoy these real-life perspectives from physicians like you. If you’re like me, you’ll come away from these articles reminded of why you became a doctor in the first place. Sincerely, Jeffrey M. Drazen, M.D. Editor-in-Chief, The New England Journal of Medicine 800.843.6356 | f: 781.891.1995 | [email protected] 860 winter street, waltham, ma 02451-1413 nejmgroup.org TABLE OF CONTENTS Questionable Admissions ................................................1 With violent snow squalls under way outside and the start of frostbite apparent on the feet of the patient with pneumonia, the ED physician finds that he can’t apply the CURB-65 score (predicting 30-day risk of death) dispassionately and send him out into the frigid world. Out of the Straitjacket ...................................................4 I see him, maybe not so clearly. He is in isolation, in a straitjacket. He’s just been committed, given a shot of haloperidol after he resisted going to the locked ward. He kicked, screamed, yelled, threatened… and now he cries. The Interpreter .........................................................7 When an interpreter hesitates before translating bad news for a patient, an oncologist realizes how little consideration most health care professionals give to these invaluable conduits who are also human beings, emotionally affected by the news they help to break. Caring for Ms. L. — Overcoming My Fear of Treating Opioid Use Disorder ........9 Like a swimmer pulled into the undertow, Ms. L. had been dragged back into the cold, dark brine of addiction. But her primary care physician, having chosen not to obtain a waiver to prescribe buprenorphine, referred her to a colleague. The Other Victims of the Opioid Epidemic ..................................11 Jerry, who has a documented history of substance misuse, is not innocent, nor does he claim to be. His vilification, however, is the result of an all-or-nothing approach to pain management under which the Perspectivespendulum has swung from one unsustainable endon of the spectrum Practice to the other in the past two decades. The Scarlet Virus .......................................................13 Confident that she could manage her HIV, Ms. M. required little intervention; appointments seemed more like visits with an old friend. She counseled other patients in the waiting room, comforting peers who remained closeted and defamed even in the 21stPhysician-to-physician century. And How Long Will You Be Staying, Doctor? ................................15 A rural physician hears that question from her patients at every visit. It implies what the Dartmouth Atlas makes explicit: physician supply is driven by where physiciansperspectives want to live, not by the health on needs of thethe community. If the doctors like it, maybe they’ll stay. The Doctor’s New Dilemma .............................................evolving practice of17 A central primary care dilemma is that engaging with patients as people makes us fall behind in administrative tasks and feel more burned out, but not engaging means avoiding intimacy that would not only help the patient but keep us from feeling burnedmedicine. out. (continued on next page) The New England Journal of Medicine is a publication of NEJM Group, a division of the Massachusetts Medical Society. ©2018 Massachusetts Medical Society, All rights reserved. TABLE OF CONTENTS (CONTINUED) Moving On ...........................................................19 A retiring physician sees the end approaching for her relationships with her patients. There will be no reunions or rapprochements, no alumni weekends. No matter how tight doctor and patient have grown, should they meet again they will be polite former acquaintances. Tragedy, Perseverance, and Chance — The Story of CAR-T Therapy ..............21 The FDA has approved the first chimeric antigen receptor T-cell therapy, whose emergence reflects the incremental insights of many scientists over decades. Its story says as much about the methodical nature of scientific progress as about the passions that sustain it. Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery ............24 When he was 19 years old, Alfredo Quinones-Hinojosa was an illegal immigrant farm worker. Today, he is a neurosurgeon and researcher. His journey from fruit picker to janitor to welder to Harvard medical student and neurosurgeon taught him about economics, politics, and giving back to society. SIGECAPS, SSRIs, and Silence — Life as a Depressed Med Student .............26 Despite the tricks in our practice exam questions, I would always nail ones about depression — if you looked hard enough, it was always hidden somewhere. But despite my finely-honed detective skills, I missed the diagnosis in a real patient with obvious symptoms. Culture Shock — Patient as Icon, Icon as Patient ............................28 In the rapidly vanishing traditional approach to patients, the body is a text that must be frequently inspected, palpated, percussed, and auscultated. The scent in the room, the knobby liver, clonus, the Perspectivesabsent nasolabial fold, the hoarse voice – suchon soundings help Practice physicians understand the patient. Letter to a Young Female Physician .......................................31 There is sexism in medicine, but there may also be a more insidious obstacle. Late in her career, a female physician admits she’s always been haunted by the fear that she is a fraud. She has perseverated over her own inadequacies and denigrated her ownPhysician-to-physician strengths. Learning to Drive — Early Exposure to End-of-Life Conversations ................33 in Medical Training Sent to visit a chronically ill patient at home, a medicalperspectives student finds that his inexperience on can be the a strength. Instead of worrying about the right words and how to say them, he learns how to listen — exactly what the patient needs as she faces end-of-lifeevolving decisions. practice of medicine. Back to Table of Contents 1 PErSPECTIVES ON PRACTICE nejm.org The NEW ENGLAND JOURNAL of MEDICINE Perspective Questionable Admissions Raphael Rush, M.D.​​ Improving Adoption of EHRs in Psychiatric Care I’ve been coughing real bad, with admitted patients who might couldn’t argue about her clinical Doc,” the man told me. He spend days waiting for a bed stability. “ couldn’t seem to stop. His green upstairs. Pressure came from all sides. sputum was tinged with blood. “Put me in a cupboard,” a pa- Years later, when I was an attend- His lungs crackled. Although his tient in the ED begged one night. ing myself, a nurse approached a fever had briefly abated, he still “Let me lie in the hallway.” resident and me as we prepared shivered beneath his rough hos- But I couldn’t: the hallways up- a discharge summary. pital blanket. stairs were lined with beds, all of “You’re a good team,” she said. Despite his illness, he looked them already full. “Thank you,” I said, feeling relieved. Violent snow squalls My attendings were sent daily pleased. “We try to take care of erased the view of the city from updates on the number of patients our patients.” the emergency department (ED) they had admitted and admon- “No,” she clarified. “I mean you window. His blanket was pulled ished to aim for fewer. They, in get patients out.” up to his armpits, exposing his turn, admonished residents to dis- We were part of a broader feet at the end of his stretcher. charge quickly and, whenever pos- movement. Between 1980 and The beginning of frostbite on his sible, prevent admissions in the 2006, the average length of stay thick soles attested to the fact that first place. for U.S. patients admitted with this was his first time indoors One evening during my intern- heart failure was cut nearly in in days. I did not need to be a ship, an attending insisted that I half, from 10.1 days to 5.1 days. senior resident to know he had discharge a woman. After a long During the same period, average pneumonia. stay, she had been scheduled to stays for women admitted for “Am I gonna get a bed up- go home the next morning. My childbirth dropped from 3.8 days stairs?” he asked. attending pointed out that her to 2.1 days. Cataract surgery once That was less clear. medical condition had resolved. required an average stay of Bed shortages were a constant “If she can go home tomorrow, 3.6 days. Thanks largely to tech- at the large public hospital where she can go home tonight,” he said. nological advances, it is now I worked. At no time was that so When I tactlessly relayed that an outpatient procedure.1 obvious as in December. Over the conclusion to her, she burst into The tools that reduced hospi- course of the month, the internal tears.

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