My pager beeps, and I’m on the phone with a nurse. A patient has insomnia and is asking for some sleeping pills. I open his chart to place an order, when again I hear that shrill alarm. I feel like a dog in a Pavlovian experiment, and it’s always bad news on the other line.
This page is an emergency call for the rapid response team. A group of exhausted 20-somethings shuffle to the bedside of a young woman with pneumonia. Her heart rate is too high and her blood pressure is too low. She needs immediate resuscitation and transfer to the intensive-care unit. I direct my interns to draw blood and order medications. I ask the nurses to give the patient oxygen and do an EKG. The patient is stabilized and survives.
Meanwhile, I’ve missed three pages from the first patient’s nurse, who is furious that I’ve been incommunicado. I apologize and finish placing the order for sleeping medicine that I had started to write two hours before. This situation plays itself out over and over every night in hospitals everywhere. Replace sleeping pill with laxative. Replace pneumonia with GI bleeding.
Medicine has a long tradition of thinking hard about priorities. The concept of triage is fundamental to the design of health care systems. We take care of sicker patients faster, and as a whole we’re stronger for it in the long run. No one dies because of one more hour awake, constipated. Sometimes, this principle clashes with the American formulation of capitalism in sick ways.
Until recently, I was a house officer at a large medical center that prides itself on its award-winning patient safety record. It is also incredibly profitable. One day, a nurse called and asked if I would order an analysis on the urine of a patient who had just been transferred from another ward. That patient had prostate cancer and required a chronic catheter to be placed in his bladder to drain urine. I reviewed his chart, and I saw no fever, no increase in his white blood cell count.
Catheter-associated urinary tract infections are common and preventable, but this patient had no signs of infection, so why test him? The nurse said that if the patient did have a brewing infection and we found it now, then we could blame it on the unit that transferred him to us.
Hospitals keep close tabs on things like catheters because they are risky and over-used, and because insurers won’t pay for care that they categorize as a complication. Hospital managers want to harness the power of competition at a granular level, so they put pressure on providers to compete in various metrics. If the patient did have an infection, of course it would have been better to catch it early, but unnecessary tests lead to unnecessary treatments, which themselves have even greater complication rates and costs. I did not order the urine test for that patient, but the system retains its “Lord of the Flies” character.
Doctors learn from other doctors in apprenticeships. They accumulate knowledge, then experience, and responsibility while reciting the mantra, “See one, do one, teach one.”
That medical expertise is passed from one generation to the next through a system of medical education into which society, families and individuals invest enormous resources. One instinct a doctor develops in this process is how to triage and do the most good for the most people. We also learn to take what our teachers have given us and use clinical experience to help our practice evolve and improve.
As a community, health care providers learn from treating patients, to the benefit of future patients. When we are patients, we all contribute to the body of medical knowledge by serving as either an exception or a rule in a single doctor’s understanding of the human body.
Triage extends far beyond the minute to minute priorities of a bleary-eyed resident. The current incarnation of American health care devotes a huge amount of resources to care for rich people while the working class struggles. The structural misalignment of incentives between health care and health dollars is profound.
Hospitals, insurers and doctors haggle over the privilege to insert the most expensive catheters money can buy into the most well-healed among us. In my view, it is misguided and cheap to think the market will correct these problems, or even that adjustments to incentive structures will fill its gaping holes. The distribution of medical care in this country is criminal. Our society has supported the health care system with its own blood, sweat and tears, and that collective knowledge and empowerment belongs to all of us.
Our best practices come from the accumulation of incremental improvements in individual patients. Humanism in medicine means accepting that our collective past is inextricably linked to our future health. We depend on one another now more than ever, and we have a responsibility to ensure decent health care for all.
Nobody knew health care could be so complicated.
