Of CABGs and Things

12 May

I was under the gun. The editor at MediMedia, publisher of P&T, was rightfully reminding me that I owed her an editorial. As my sense of duty overcame my commitments to other “important matters,” I scrambled to find my folder of potentially “interesting things” to write editorials about. As I sorted through the hodgepodge of materials, I wondered to myself, what was I thinking at the time when I thought these ideas were interesting?

I half-heartedly started on something . . . and then decided to take a break (ahhh, the joy of procrastination) to skim through my weekly miscellaneous pile of articles, titles that had caught my eye from the tables of contents of various journals.
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“Coronary Artery Bypass: A User’s Manual,” although not a sexy title, still elicited enough of my interest for me to give it a quick read. It changed my mood for the day and for some time to come.

The article title is deceiving. The piece describes the experience of a physician, a distinguished cardiologist at UCLA Medical Center, going through the pre-operative, perioperative, and postoperative process of coronary artery bypass graft (CABG) surgery. This procedure is a major source of “bread and butter” at many hospitals; the procedure pays well, works well, and has a significant clinical and operational knowledge base surrounding it. I was drawn to the article because of a negative post-CABG event that affected a close family member several years ago.

Dr. Perloff, an accomplished academic clinician, writes about the onset of his cardiac symptoms, the ambulance ride to the hospital, and his experience in the emergency department. The other “things” that he describes include the medical procedures, his personal medical history, the various processes and types of care, the pharmacy issues, and procedure-related complications. The author humbly acknowledges where he and the health care system have worked well and where major failures have occurred.
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This article is not about computerized physician order entry (CPOE), medical errors, or heroic efforts. Dr. Perloff’s experience, for the most part, involved a typical CABG in an older patient, with the added elements of exceptional

Has health care become a commodity, delivered in an assembly-line fashion, that no longer considers patients’ experiences?

patient clinical knowledge, privilege, hubris, luck, and the reality (perhaps better described as a horror) of current post-discharge planning. Dr. Perloff’s spouse, a nonclinician, also provides a narrative of events at home, a perspective that is almost never reported in the medical record.

Please try to read the Perloffs’ account. I realize that the article might be from a journal that you do not routinely read, but it is well worth the effort. I found myself reflecting upon the following broad range of issues:

  • Social morbidity has a major impact on clinical outcomes.
  • The medical establishment continues to focus on acute care, with only a token interest in post-discharge care.
  • Good health is a privilege, but most people take it for granted.
  • Clinicians deal with what they know best, and they prefer not to bother with the rest.
  • Boundaries for the continuum of care are self-imposed and tragically flawed.
  • There is more than one level of care; unfortunately, the best level is based on a patient’s status and income.
  • Information technology and evidence-based medicine are sometimes thought to be the answers to the problem of quality, but are they?

Formulary decisions, coverage criteria, model guidelines, state-of-the-art therapies—these “things” are all secondary to Dr. Perloff’s experiences that point to a massive hole in our critical thinking about serving and healing patients. Has health care become a commodity, delivered in an assembly-line fashion, that no longer considers patients’ experiences? The system needs to consider making serious efforts in recruiting professional discharge instructors, re-establishing house calls, limiting quick-discharge policies, and providing reality-based home care.

This article does not provide concise recommendations, such as we would expect if we were reading a clinical trial or a health policy document. Instead, it led me to react with uneasiness about the collective health care community, which can perform acute-care miracles but often ignores the “quality of living thing.”