When to hold back?

Yesterday I led a case conference regarding ambiguous care for a complex patient. It was with regards a patient with shoulder pain with a small labrum tear, multiple comorbidities, severe illness anxiety who was maxed out on medical therapy, pain refractory to physical therapy and other conservative interventions. I hesitated very much on referring her to a surgeon because I knew she would likely get a surgery of questionable benefit with possibly worse outcomes. There is gross incentive for the surgeon to still perform surgery and it’s hard to refuse a patient when they likely will just go find a surgeon who will do it. I know that was the pathway and that is what happened. And then she got worse.

I don’t think we think often enough about the ambiguity in health care, probably largely from social pressures with expectations to have answers and be perfect. One of the things that was mentioned was the spectrum of testing for everything and missing nothing and testing for few things and missing some things. I mentioned this to an intensivist and he related it to the aggressiveness of care sometimes in the ICU. You can withdraw care from everyone who is seeming like they are going down a poor path or you could continue full force interventions all the way up until death is obvious.

What this is getting at is this idea often tossed around that we should test if we can and we should intervene if we can. People think getting an MRI is benign and if they had the option most would likely want to get an MRI of their whole bodies to find any possible disease. The problem with this is that we often find things that look suspicious but will never be problematic and have no way of knowing until we biopsy them or resect them. This is largely why most of us in healthcare are reluctant to pursue tests that don’t have clear purpose. Patients don’t often understand this ambiguity however so therein comes some need for paternalism to protect patients from themselves. Patients want the most educated care, the most testing, the most interventions and while we as healthcare professionals are sitting there desperately wishing they would back off and accept fate, they continue pushing.

In the ICU we often will do full force care on patients who are extremely ill and more often than not it is futile. But sometimes, every now and then, a patient pulls through and we’re terrified of how many patients we have backed off care for who may have made it out of similar circumstances. That is a terrifying prospect for a physician and very similar to the fear invoked by a test not ordered that would’ve revealed a cancer that could’ve been treated. This is horrifying at my stage of my career. I desperately want things to be more black and white but the ambiguity of medicine is what makes it so academically intriguing. If there were clear answers, algorithms and pathways would takes our jobs.

Part of me wonders what good we’re actually doing. Repeating biopsy after biopsy after biopsy on a somewhat suspicious cervical lesion, following year after year after year, all while the patient is dreading coming to see us, wondering which time they’ll find out they have cancer or find out that everything is fine and all the probing was for nothing. Most patients it seems want answers; that at least seems fairly universal. And a lot of doctors will justify that when they go down these abysmal pathways that are certainly causing harm.

I feel like we as medical professionals in the midst of trying to prevent disease and fix everything little problem have created this global illness anxiety and health awareness that is causing more harm than good. I worry more for the joy of life and the end of life prospects of the patient who pathologically exercises and eats a pristine diet full of the latest fad supplements and whose BMI is perfect who tries desperately their whole lives to prevent heart disease with fish oil and to stifle the effects of antioxidants with Acai than the rural Montana farmer who hasn’t seen a doc since they were a kid who comes in at 82 with a raging terminal cancer. One of those people perseverated over their health their entire lives and often I am concerned those people forgot to live. And the other lived a good life and is often content to pass.

Maybe I am too cynical. Maybe I am jaded. But after witnessing the atrocities that the health care system puts people through with aggressive management, and especially the discrepancy between the care the wealthy get for unnecessary interventions and the crumbs the less well off get, the limited support available to the young and otherwise healthy compared to the insane expenditure on people who will inevitably die soon, I understand my cynicism. It isn’t unfounded. And understanding where this introspection comes from I think is even more important. I see the suffering we invoke on a regular basis, the number of people we strip from their homes to die alone in a cold, stale hospital. I went into this job to help prevent suffering. I want to help people’s lives be a bit better. And I don’t think we’re doing as good of a job of that as we could be.

A moral dilemma of placebo in american healthcare

I have been caring for patients for nearly a year and a half now in residency and have come across some of the more subtly haunting realizations in American healthcare. Recently I watched a presentation by Lorimer Moseley on pain psychology which highlighted some of the variables in placebo effect. Early in my training I naively believed in the therapies I was providing. Things needed to be more clear cut and I sought evidence based medicine by tracking down randomized controlled trials or meta-analyses relentlessly. The further along I am the more I have realized that a significant portion of the things we do in medicine are either completely useless or of questionable efficacy. Because of this I realized that largely my patients were having benefit because of natural history of their disease process (aka they were going to get better independent of what I did) or due to placebo.

The impacts of these findings is not insignificant. I think it is fair to say the ambiguity of efficacy of therapies in medicine are not only misunderstood by patients but horrendously understated by medical professionals. The perfect illustration of our inability to provide confident care is a statistical measure called number needed to treat or NNT for short to evaluate how many patients we need to treat for one person to have benefit. To tell a patient, “I would have to treat two of you to obtain this therapeutic benefit,” and to make them aware of potential adverse events would likely turn off several patients to those therapies. To make it transparent that most of our therapies are horrendously worse than an NNT of two would likely create total distrust in the healthcare system, especially when we are talking about unfathomably expensive and invasive things like organ transplant or orthopedic surgery. The reality is that even with a solid diagnosis and a good treatment, the chances of patients having quantifiable benefit is still very low. Add in diagnostic ambiguity and it makes evidence based treatment a total crapshoot.

The reason I bring this up is because I am battling an ethical quandary. Placebo is effective in many cases but very dependent on a whole host of variables. I know that the more I sell my placebo, the more I tell a patient that a therapy is likely effective, the more “doctorly” I am dressed, the neater my hair, likely the better placebo effect I may have for my patient. My patient would by all accounts benefit from those things. The ethical dilemma comes in when I am facing the infinite complexities beyond the quantified therapeutic benefit. For example, is it okay to tell a patient that I believe a therapy will work for them when I am unsure? When placebo works for approximately one out of three patients for many given conditions, is it okay to tout a mild therapy as likely beneficial to increase the chances of benefit even if it may be minimal?

Additionally, what is my obligation to help my patients with my appearance? If you google image search “physician” you’re bound to get countless stock images of doctors of all races, genders, sizes likely wearing a stethoscope and a long white coat. Interestingly there is an appearance of a physician that elicits the greatest placebo response. For example, a female physician was able to provide greater placebo effect than two males colleagues in a trial of 120 people being treated for IBS. The reason this matters is because this appearance actually impacts quality of care delivered. As a younger, frequently clean shaven and youthful appearing physician my judgement is frequently questioned and likely my therapeutic benefit for patients suffers as a consequence. And now I know that, as a male provider, referring to a female colleague for treatment of my patients with IBS would likely promote better outcomes for my patients.

I have dealt with many horribly inappropriate comments on my appearance in the clinical setting by patients and other healthcare professionals. I had a nurse ask me if I had gotten my driver’s license yet, countless obstetric patients decline my care because of my apparent gender, a physician’s assistant tell me I needed to iron my shirt because I looked unprofessional, dozens of patient’s commenting on my age, and a frequent distrust of my credibility as a generalist practitioner. These verbal patients and colleagues are the easy ones to deal with because they state their opinions and I am able to address them. The subtler, less vocal biases are likely the ones that compromise my therapeutic impact. Am I obligated to iron my shirts and wear a white coat to appear more as the classical image of a physician? Should I keep my beard year round to appear older to appeal to the ageism in my older patient panel? How in 2020 are we advocating so hard for dissipation of discrimination based on gender identity and yet so many patients declined my care because I identify as a male? Am I obligated to shape my appearance and refer to differing appearance providers to better help my patients?

To add complexity, our medical system is based on fee for service similar to a car mechanic. In mechanic work the model is that the diagnostician is the same as the interventionist and we know this model creates tension and likely frequently unnecessary interventions and cost to the customer. In medicine I could derive direct financial benefit from a certain treatment and likely I would receive variable compensation for various therapies independent of their indication or efficacy.

These questions are not new but I think not as discussed as they ought to be. Placebo effect is infinitely complex and I certainly will wrestle with it for the entirety of my career. More related to the financial incentives of treatment, currently the American healthcare system by nature absolutely prevents me from feeling like I can practice ethical care for my patients. So long as there is a financial incentive for any healthcare providers to deliver care, with well documented greater financial incentives for less evidence based, more invasive care, we will not be able to rest knowing that the career of a physician is a fundamentally altruistic one.

Bikepacking Pisgah

I looked and saw the chance of rain was 0% for the next two days. Today, large raindrops clacked on my windshield and a dense fog surrounded my car. We couldn’t climb because of the weather today but I needed to seize the opportunity for an adventure tomorrow. In my car I have all the tools for an epic adventure: a full trad rack, a sleeping bag and sleeping pad, a hammock and a tarp, and a mountain bike on top. The mountains are open, I just needed to decide what tool I wanted to use to explore them. Continue reading Bikepacking Pisgah

Longs Peak Winter Cables Route Summit

During the summer five years ago, for a last hurrah before starting med school, I opted for a cross-country road trip. From Richmond, Virginia I beelined across the country to Rocky Mountain National Park as my first stop. When I caught my first glimpse of the beautiful craggy summit of Longs Peak, I knew I wanted to hit up the class 3 scramble route to get to the summit. After years of living on the East Coast with mountains no bigger than the foothills at the base of the Rockies, I was hooked at first sight. A few days of acclimatizing got me to the Boulderfield, the campsite at 12,700 feet elevation at the start of the scramble part of the Keyhole Route to the summit of Longs. While eating dinner and chatting with another camper, we saw two guys rappel down another route on an imposing face and come strolling through the campsite. I asked them how they got into that and got the scoop. Step one: join the local gym. Beyond that everything else would fall in place. It seemed like an arduous process for someone who was used to being rapidly self-taught. But as I’ve learned, mountaineering is no joke and definitely takes time to get down. Continue reading Longs Peak Winter Cables Route Summit

Winter 14ers for Beginner Mountaineers: Top 10

With the fall and winter months approaching quickly, Colorado mountaineers are whipping out the crampons and double boots in lieu of the trad rack and trail runners. But if you’re new to the big mountains, the cold and snow can be quite intimidating for good reason. If you’re looking to bag some winter 14ers but don’t want to risk your life to do so, this list list can help steer you to some solid safer climbs. Whether you’re looking for a more intense climb than the summer hikes or love the solitude of the off-season, winter 14ers can be an amazing experience.

However, before even considering attempting any of these winter 14ers, I would recommend that you have experience with climbing 14ers or at least 13ers in the warmer months, or at minimum go with someone who is familiar with the mountain and the cold. For nearly all of these climbs, I recommend having at minimum microspikes and trekking poles. It was a very rare day that these aren’t essential pieces of gear. In addition to that, most of the climbs call for snowshoes, especially after a storm or on the less travelled routes, and many of them necessitate an ice axe and the experience with using one. 10 point crampons are rarely if ever necessary on most of these routes.

This is not meant to be an all inclusive guide to each climb, just merely an introduction to help you decide which climbs to do. Always check weather and route conditions beforehand. I’ve linked to some helpful resources at the bottom.

The short and sweet winter 14ers:

1. Quandary Peak (East ridge)

Quandary peak winter
The route up Quandary follows that ridge and kicks up there in the last third.

Continue reading Winter 14ers for Beginner Mountaineers: Top 10

Bikepacking the Blue Ridge Wrangler

Bikepacking:

verb

  1. a portmanteau of biking and backpacking

  2. combing traits of long distance bicycle touring with the minimalist priorities of backpacking, usually favoring trails and gravel over paved roads

  3. Potential for laughably massive amounts of suffering and hilarity

Day 1, Blue Ridge Wrangler

We set out at 8pm with a sensible goal of getting a few miles into the Blue Ridge Wrangler, a 185 mile bikepacking loop, just to get away from the road for a night of camping. Neither I nor my friend Scott had ever bikepacked before and we were about to ride away from the comfort of our cars. Onto unknown trails. Thirty minutes before sunset. On gravel bikes.

Bikepacking Blue Ridge Wrangler
My trusty steed

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Rock climbing Buzzard Rocks near accident

This past weekend I went climbing with a few friends at Elizabeth Furnace up in Northern Virginia. On Saturday we hit up a small roadside crag called Talking Headwall where we cranked over some pretty fun well protected roofs. We wore ourselves out and then the next day went to go climb Buzzard Rocks on some classic slab routes, a nice two mile hike up the mountain from Talking Headwall. It was a great weekend with some super fun climbing ranging from crimpy face climbs to juggy overhangs to featureless slab but you may deduce from me writing about it that in classic Grayson adventure fashion, things didn’t quite go as well as intended. Continue reading Rock climbing Buzzard Rocks near accident

Balancing adulting vs adventuring

Nearly constantly people are trying to talk me out of doing the things I love. My mom cringes when she hears plans for the next adventure. My aunts and family friends comment on facebook pictures demanding that I come home right this instant. Park rangers warn me of the dangers up above, ski patrol reminds me they won’t rescue me, hikers exclaim how dangerous rock climbing is and how many people die doing it. They’re not wrong to have those thoughts and I’ll admit that to reconcile those sentiments and my own fears with my cravings and love for adventures in the backcountry is a constant struggle. It’s the mountaineers dilemma to balance life at home and family with our own very selfish need to explore. Continue reading Balancing adulting vs adventuring

Climbing Looking Glass Rock

We were dilly dallying, procrastinating on packing, wanting to be there but not wanting to do the 6.5 hour drive to actually get there. So we farted around, took dogs for a walk, got some dinner, took dogs for another walk, and finally around 6pm we were ready to go. We were headed to Looking Glass Rock in southwest North Carolina, closer to Birmingham, Alabama than to Richmond, Virginia. We had deliberated for a while on where to climb. We knew we wanted something the trees, something south facing, some place warm-ish for late December, and ideally some place for trad climbing. Stone Mountain in NC had been our original goal but highs in the low 30s thwarted our desire compared to highs in the low 40s at Looking Glass Rock. So we committed to a longer drive for warmer temperatures and cruised southwest. Continue reading Climbing Looking Glass Rock

11 of the best climbing videos ever

1. James Pearson on “The Walk of Life”

James Pearson making the first ascent of The Walk of Life with runout poorly protected featureless slab with a HUGE whipper. Doesn’t get any better than this. “You start off and you climb almost 10 meters with no gear and then you get a really, very bad nut which is, maybe you’d hang your coat of it.”

Continue reading 11 of the best climbing videos ever

Adventures of a medical student