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Comment by kbenson | Hacker News Reader

> Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.

What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?

Having to relearn everything might be a problem, depending on what it actually means, but as long as we want a normal human being as a doctor, they will cycle over time as people start and end shifts, and they will need to learn what happened before their shift started (and they may receive patients from multiple doctors leaving over their shift, making 1-on-1 hand-off infeasible).

It's easy to call this out as a problem, the question is what's the alternative that's better?

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In addition to this, many doctors want to re-take the history from the patients and re-examine them for themselves, rather than rely on a brief handover or potentially sub-optimal notes from another doctor. Clinical signs can be subtle, as can points in a patient's history that may point to a diagnosis. I see patients often frustrated at being asked the same questions by each doctor they see, but most of the time this is in their best interest.

I try to preempt the frustration by saying that we each take our own history for the purpose of making sure no details are missed, but rest assured, I’ve gotten the overview from your other docs. I then make sure to complete a sentence for them once in a while, to evidence that that is the case.

A good percentage still get frustrated. Can’t be helped. Patients reshape their narrative, remember new details, just plain open up more to some docs, etc. the repeated history taking really pays off in improving patient care.

Where I find patients get most frustrated is when docs come in for a specific job, and patients don’t have the health literacy to understand what that is or is not. “Doc, can I go home today?”

  “ I’m just the consulting cardio here to check out your heart for your primary doc, Doc McStuffins, I have no say in that at all, you need to ask McStuffins.”

“Oh. But when do you think I can go home?”

There’s no good response to that. No one wants to cough up cash to pay for health professionals time to repeat themselves all day long. But the patient that’s asking? They want that answer. They don’t -feel- like they’re asking an inappropriate or stupid question.

I think this hits the nail on the head. There is a huge information gradient between most patients and the doctor and perfectly bridging that gap takes more [time|money] than any system is willing to support.

I think about this when it comes to providing a patient with "informed consent" for a particular treatment/operation. What does "informed" really mean in this case? A brief overview of the main risks and a couple of statistics? Or a thorough understanding of the pathophysiology of the disease and the trial data supporting the therapy? How long is a piece of string?

It's tough, and I get that. I also know that as a person with neurological trauma that makes speech difficult at best, having to recall what amounts now to 50+ pages of chart every 4 hours is... BS. You might as well be telling someone with a broken ankle to run up and down a flight of stairs every so often while they try to recover.

There is also an argument that, unless there is some sort of ongoing peer review (they did this during my Oncological Adventure(tm)), you're increasing the number of moving parts, and thus the chances of a breakdown. Charting errors are a significant source of medical mistakes.

The problem as I see it is not the intent of the procedure, it's the while (1) do x; mentality. There should be some "ifs" and mitigating functions instead of a hardcoded 1

Each doctor also has an incentive to re-examine the patient so they can bill for that examination.

No, they don’t.

Most patients get admitted under a DRG, which is a lump sum payment. It’s true that doesn’t apply to every patient, but enough of them that doctors habits aren’t going to be shaped by the minority.

For that matter, you can come in and see a patient without asking the same history as the guy before you, if you’re just checking a box for a billing.

And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money). What you describe is a pitfall of private medicine.

> And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money)

This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions. In fact, you literally go on to mention as such in your next sentence.

It turns out that having an incentive to "save the system money" results in a different set of clinical decisions. And no, those don't always work out in favor of the patient. (They're particularly problematic for the patient in cases of long-term care, which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).

> which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).

It might be true that the NHS has poorer outcomes but I doubt that this is necessarily the cause. I live in Norway and have considerable recent first hand experience of the health system. I'm confident that they have incentives to save money too. In fact my wife's cancer nurse when explaining why there was a delay in starting the day's treatment said that preparations like Avastin would not be ordered from the pharmacy until the patient was both present and prepared for treatment because they could not afford to throw it away when the patient didn't turn up or turned out to be too ill for chemotherapy.

It is broadly speaking the same idea as the UK NHS but apparently has better outcomes for diseases like cancer. There are fees to pay, similar to an insurance excess or what the US calls co-pay; but those fees are affordable and capped to a couple of hundred pounds a year.

This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions.

Not to mention that many if not most NHS-employed doctors run private practices on the side. Some only spend a day or two a week on their NHS duties. Others such as GPs are NHS-branded, but every GP practice is a private business that bills the NHS for time and materials.

In a discussion of NHS vs private practice, the fact that some (certainly not most) NHS-employed doctors also do private work, has no baring on the incentives placed upon them within their NHS employment.

I am certainly not saying the NHS system is perfect, and all private medicine is bad, so if that is the impression you got then perhaps I was unclear.

In almost every single clinical situations within an NHS hospital that I have seen or can think of, the clinicians treating you will not receive any extra money, bonus, promotion, etc. for the treatment they provide you or do not provide you.

I have lived in countries with more private systems, where there is a direct relationship between what treatment/investigations you receive and what money ends up in the doctors pocket. For example, a private doctor in HK referring for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at a private MRI clinic which, provides a percentage of the (expensive) scanning fee back to the referring clinician. Contrast that in the NHS, no one gets given money for sending a patient for an MRI scan, and in fact, if it isn't going to change the management of the patient, the request is likely to be refused to constrain resources. In the HK system, neither the doctor nor the MRI provider is incentivised to not do the scan, quite the opposite.

The NHS system is not perfect, but pointing out different the pros and cons of different incentivisation structures that do have an impact on patients is not something that is a "meme that needs to die"…

The NHS does worse in treating cancer than other countries, but many of those countries (Germany, France, etc) have public health care also. It's not clear that the difference in performance is because of public, vs privately, funded medicine.

> The NHS does worse in treating cancer than other countries, but many of those countries (Germany, France, etc) have public health care also. It's not clear that the difference in performance is because of public, vs privately, funded medicine.

Right, I'm saying that the difference isn't simply a matter of private vs. public funds, the way OP claims. You can really trivially create a private system that has the same bad incentives with respect to costs and care as the NHS does. You can also trivially create a public system that has the same bad incentives with respect to costs and care as the US does.

That said, Germany and France aren't really publicly-funded as well the way people think. Both rely on a private network for care delivery (unlike the NHS), so it's a bit of a stretch to say that they're "public health care" systems. Even if you're looking at funding, in those two countries, taxpayer funds only cover 75% and 70% of expenses, respectively.

We can start by treating this as an important problem and tasking ourselves with looking for and finding alternatives and putting political/financial pressure on these institutions to consider them.

Just asking "but what are the alternatives" isn't productive in itself, and doesn't really carry the conversation forward. It more likely shuts it down as a hopeless problem. We can do better. It's not hopeless and we're not powerless as a collective.

I'm sure there are alternatives but we're not looking for them very well. We could start there. I'm doing my part by bringing this up in conversation whenever it's relevant and getting to know my state representative and state senator. I also make noise towards the hospital's admins in the meanwhile.

---------------

Also, the article discusses possible alternatives. Here are a couple of paragraphs from it:

"This begins with our own training. Certainly doctors must understand disease, but medical education is overly skewed toward the biomedical sciences and minutiae about esoteric and rare disease processes. Doctors also need time to engage with the humanities, because they are the gateway to the human experience."

"To restore balance between the art and the science of medicine, we should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership."

The problem isn't really the 20 minutes it takes to get up to speed, but that each patient visit is only allocated to get 15.

So I took my dad to the hospital a couple times in his last year or so, and I think the main thing every patient needs but doesn’t necessarily have is someone to do the top-level coordination. There might be a surgeon and a hospitalist and a cardiologist and a neurologist and whoever, but no one is actually in charge. Most hospitalized patients mentally check out—humans don’t do well in captivity—so unless you have a family member advocating for you, you’re kind of fucked. Doctors come and go, but none of them take responsibility for the patient’s overall well-being.

It doesn’t require 24-hour shifts or even a medical degree to do this kind of coordination. I did it and I have no medical training whatsoever. But it was pretty important work, and my dad would have been lost without it.

What's the alternative?

Methodologies such as Kepner-Tregoe explicitly make handovers very easy, used very effectively in manufacturing, energy, and other industries. But God forbid that almighty doctors should ever take any advice from outside their profession.

The doctors individually spending 5 quiet minutes reviewing the case files of the patients they were about to treat BEFORE they arrived.

That's not modern reality and its shameful.

That's not modern reality according to whom?

My spouse is an MD and she spends a minimum of 45 minutes before her shift reviewing her patients' charts. After work, at home she tidies up patient notes to ensure the next person gets an efficient summary of the patient. Then after dinner she's answering a bunch of instant messages from patients on the hospital's patient portal and doing any prep necessary for the next day.

Programmers would be collectively rending our garments if we had to do anywhere near the amount of unpaid / off-the-clock work as doctors do.

On the other hand, at least some of us would give an arm or a leg to be able to do work as impactful and useful as doctors.

This was the desired behavior. Its not that they reviewed existing info to check for changes, its that they knew nothing. Like the last 30 minutes of questions and chart didn't exist. On the side of the patient, this does not inspire confidence. It projects a sense of confusion and disorganization.

Twenty years ago when I did tech support for a living, I had a series of questions worded in very specific ways I would ask at the start of a call. Sometimes the content of the answer was the useful part of the response, sometimes how the answer was said.

More often than not, if I got someone on the other line that seemed to know a bit, skipping the questions ended up being counterproductive, as I would assume some knowledge about a specific item from the other end that didn't exist (but other knowledge did). I learned to trust the process, and glean the extra bits of information that weren't what the other side was trying to convey, but did nonetheless.

I think it's a mistake to assume that just because the doctor asks you questions and doesn't always seem to take into account a prior answer the doctor is not listing. I think it's more likely that they have learned that the small percentage of time that asking similar questions in different ways has led to new, important information has led them to be careful and methodical, even at the expense of patients thinking they aren't listening.

When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.

His very countenance rippled like the sea, and the sound of my own voice came back to me, distorted. ... it was how I affected his sounds and how she affected mine that transmitted the message. - SMAC

I don't disagree with what I interpret as the intent of your message - that there is real value in process, question repetition, and not jumping to conclusions.

I do think it implies a false choice at the end though. A doctor can imply they care / listen / are familiar with your case, while still asking insightful questions and probing for relevant changes.

[Analogy] As there are many engineers here, consider this contracting example: how would most companies respond if, for a project, at each meeting, the contractor sent a new representative, who asked all the same questions as the first meeting, could provide no status updates, and many reps suggested apparently different solutions, platforms, or approaches?

> When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.

This is an important point but I feel you're approaching it from a very short term view. Look at Pakistan, for example: after the CIA used a vaccination program as cover for a genetic testing scheme meant to find Bin Laden [1], there was (and still is) a significant impact on the Pakistani and other population's trust in their domestic healthcare industry [2]. Even if it was a real Polio vaccination program that saved thousands of lives in a purely utilitarian short term calculation, the damage that distrust causes long term can far outweigh the benefits. Worst of all, due to the nature of that distrust, measuring that damage becomes so much harder.

The point is, doctors don't just need their patients to trust them, but to trust the institution of modern medicine and healthcare as a whole. They need the patients to trust their nurses, pharmacists, specialists, and technicians just as much as the primary doctor. Given how critical patient cooperation/honesty and preventative care are to clinical outcomes, I don't see any convincing evidence that patient perception isn't just as important as the rest of the process.

[1] https://www.theguardian.com/world/2011/jul/11/cia-fake-vacci...

[2] https://www.scientificamerican.com/article/how-cia-fake-vacc...

> its that they knew nothing

That does sound rather concerning if that's the case!

As a medical student about to sit my final exams, I have shadowed hundreds of doctors of different grades and specialties in many different hospitals and family practices, and I don't recall ever seeing a doctor not review the notes before seeing a patient. Often here in the UK at least there is a large amount of time pressure and it would certainly be desirable to have more time to review further back, in more detail, etc. but given in general practice there is a 10 minute slot per patient, there are systemic limits on this (that would be nice to address).

On the other side, trying to figure out what is going on with patients is much more complex than catching up on notes and trying to get a "delta" update from them about what has changed in the shortest space of time/words as possible. The number of times I have taken a history from a patient and then less than half an hour later observed them add hugely important extra details that were omitted previously is pretty large. Often, it is far more helpful and illuminating to ask a patient to tell you what has been going on in their own words, even if you think you have read it all in the notes. I have often seen more senior clinicians pick up subtle clues that were missed by more junior clinicians, or ask a pertinent question that was not asked before.

And finally, on a more pragmatic basis, doctors take a lot of risk on board whenever they treat a patient. Patient's get tired of people asking them if they have any allergies for example, but when it's your name on the prescription, and your ability to sleep and your license on the line, you may well decide to ask the patient again rather than rely on what some previous clinician in some previous setting has written down on the patient's file. In a similar vein, a lot of practice is not black and white. If a junior with limited experience writes that a particular clinical sign is positive in the notes, you may well want to repeat that examination to re-assure yourself before you allow it to guide your treatment.

None of this is excusing unpreparedness or poor practice, but hopefully shines a little light on some reasons why it seems like there is so much needless repetition.

You bring up good points and your last is particularly relevant in this case, as the patient arrived with what were termed simple problems, was expelled due to lack of finances, died suddenly a week later apparently due to MRSA contracted at the care facility, and the family is now considering malpractice. Your name on the line is a very real risk.

Unfortunately, I expect this may create a lawyer averse culture where process is as repeatable as possible, because in the event of a suit, systematic process is a solid defense.

To play devil's advocate, patient handoffs are incredibly risky and one of the biggest causes of medical error. Retaking patient history is one of the best ways to reduce that risk.

Think of it like talking to a project's stakeholders yourself rather than relying on requirements gathered by somebody else.

5 minutes lol. From a surgery perspective: Getting a consult as an intern on a patient with a big case file is like (at least) 30 minutes of reading notes, then you talk with the patient, then you talk with your senior, then you and the senior go talk to the patient, then the senior talks to the attending (depending). Sign out (patient hand off) can take a while depending on the size of the list but I don't know any other interns that don't stalk the charts before they are about to come in so it's usually just a quick brief on each patient and what therapies are going on. Did I mention you do sign out (on trauma) after having been at the hospital for 24+ (sometimes 30 depending on attending) hours? Things can and do still get missed.

Part of this can be solved by having better care managers associated with each patient (primary care doctors), who can share relevant information with different parties. Works mainly for chronic care. In the case of acute cases, information needs to be readily accessible in a format that is interpretable by doctors when they go through the process of assessing differential diagnoses. That information is not captured well right now, hence the ask for patient's history with each new physician. Personal health records with smart annotation of key pieces of information can play a part in solving this problem, but are only part of the answer. One of the most dangerous periods in the emergency room is the transition of one care team shift to another. It takes forever, and often leads to key information loss.

I don't really understand is this concern about having to "relearn" everything when doctors change shifts, because that's not how it works. Maybe that's how patients perceive it, but generally before each shift ends, in order to be relieved of your shift, you have to sign your patients out. This is basically an hour long phone call with the next doctor, where you tell them everything that happened for all their patients.

Is there really a need for 24 hour doctor visits most of the time?

No. Doctors can have mostly normal 8-hour workdays, 5 times per week. Nurses administer drugs and monitor the patients. If a problem arise, they can call the doctor in charge of the patient or bring the doctor doing the night —or weekend— shift.

This is what you responded to:

>> Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.

> What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?

This is from your response:

> Is there really a need for 24 hour doctor visits most of the time?

The exact situation described is hospitalization. Pointing out that most treatment may not be on a 24h basis is not relevant here.

In the last few years I've spent almost a triple number of days in hospitals (not as a patient). I can tell you from first-hand experience that most patients that are hospitalized —except in the ICU— do not need multiple doctor visits per single day. Maybe they need a couple different specialties, but certainly they do not need multiple doctors of the same specialty in the same day or more than a few specialties.

As has been pointed out in many submissions on HN about USA's medical practices, the main reason you get many visits is to inflate your bill. I think someone even wrote that he was charged $600 per 1-minute visit during his stay in the hospital.

The alternative? How about not artificially restricting the number of doctors in the system so the ones in it don't play musical chairs and ones aspiring to don't do 28-hour shifts?

Artificially restricting? Could you elaborate? I was under the impression that the only restriction on the number of doctors is the ability for people to get through med school.

There's a fixed number of seats in medical schools and a fixed number of residency slots. When you add foreign doctors that would like to practice in the US to medical school graduates, there's less residency slots than doctors that would like to take them.

Most residencies are paid for by Medicare. Big hospital systems just can't seem to find the funds to train doctors on their own.

Gracefully dying?

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