Deborah Kotz, a senior writer at U.S. News & World Report, spent about two months at the University of Maryland Medical Center, meeting many of our doctors and patients for a feature story in the magazine’s 2009 “Best Hospitals” issue. Her article, on the “Art of Medicine,” describes situations in which the best path to take is not always clear-cut, and patients and their doctors must make some hard choices. This interview with Kotz offers a behind-the-scenes look at this article, Kotz’s impressions of UMMC and its care providers and much more.
Deborah Kotz: The article was focusing on one hospital -- the University of Maryland Medical Center in Baltimore -- and we came up with this idea because a number of us on staff had often experienced medical situations where it’s been difficult to make a decision. We wanted to look at some common scenarios and some not-so-common scenarios of things that go on in hospitals to try and find out what actually goes into making medical decisions, especially ones that don’t necessarily have strong science behind them, to suggest which way a patient should go in terms of treatment.
Kotz: We do a “Best Hospitals” issue every year and we’re always looking for a unique way to feature hospitals to show our readers what goes on inside those hospital walls. This can help them prepare in case they are unfortunate in that they have to use a hospital themselves or take a family member to the hospital.
Kotz: We were looking for a large teaching hospital in a big city that had multiple departments -- that had a Shock Trauma Center; that had a Cancer Center -- and also had patients from various walks of life. We wanted to try to find patients who were perhaps Medicaid patients from the inner city as well as patients who were professional -- there was even a patient who was a professor from the medical school. We really wanted to get a variety of various opinions, various perspectives from different patients.
Kotz: I was definitely working very closely with the public relations folks at UMMC, who were very helpful to me in connecting me with the doctors and patients. There was also a fair amount of legwork in my own office, involving Medline searches -- trying to research certain diseases and conditions to figure out what some of the evidence-based medicine was and where there were gaps that doctors may be encountering when they were trying to counsel patients.
Kotz: I’m hoping I got a pretty representative feel for a large teaching hospital, of residents interacting with doctors, doctors interacting with patients and nurses; a feeling of how that synergy really worked. I also got a sense of what goes into determining, especially for those tough decisions, how these things were weighed and how various opinions factored into the course of decision making. I also got to see how these doctors and nurses and various medical practitioners communicate to patients once they actually came to a consensus, and how that was conveyed to the patient.
Kotz: I think the honesty of the doctors. They were really able to communicate to me how difficult it was sometimes. When I said that the working title of the piece was “Art of Medicine,” they said, “Oh, we do that every day. Every day we have patients where it’s not a ‘by the book’ case,” where they can’t just open up a textbook and say, “We know exactly how to treat him because here it is laid out for us.” So, I did get a sense from these doctors that it was difficult sometimes, that there wasn’t always an easy answer. I got to watch them trying to tell patients what their options were, what the risks were of the procedure, what the benefits were of the procedure, and to really help patients make a decision based on that information, and sometimes to help them through those unanswered questions.
Kotz: Each one had some pretty unique take-home messages. I was struck by cases of doctors who were frustrated by the lack of research in certain areas in order to guide them. There was one doctor who talked to me about what he does when he encounters a brain aneurysm in a patient. Oftentimes, these aneurysms burst before they’re even discovered, but when he does find one in a patient and it’s a small aneurysm what does he do? Well, he was saying the very procedure that he does, the coil procedure, does have some risks. It has the risk of causing the aneurysm to burst, and there is a small percentage of deaths in those instances, but if you do nothing the patient also has a risk of dying. So, he said to me, “You know, I scan the literature, I look for the answers and the studies, but in these particular cases, there really is no consensus. The researchers themselves argue back and forth about what to do.” I encountered doctors who were practicing the best medicine they could practice, but who often feel frustrated because they just don’t have those medical answers. I think it’s important for patients to realize that doctors don’t always have all the answers for them.
Kotz: I think that maybe my preconceived notion was that it would be kind of like an assembly line, that there would be almost like a tight system in place for everything; that things would be more predictable than they were. And I was struck, especially walking into surgery -- the surgery I observed of a cancer patient -- that I was able to really see doctors having to change course or alter the way they were doing things in the moment, once they opened up the incision and saw what was inside the human body for themselves. It often changed their plan of action because, even with all the high-tech imaging tests that we have, they don’t necessarily show you what’s inside.
So it is interesting. I think a lot of people often think, “Oh, you know, all I need is an imaging test and that’ll tell the doctor exactly what’s going on, then they’ll go and they’ll fix exactly what the problem is,” but the human body is so much more complicated than that, so we want to make sure we have the best who are actually taking care of us.
Kotz: The point of doing this piece was to allow people to understand that when you go into a hospital, and you’re in this sort of emergency situation or even the planned situation of an operation, that there may be things that change, that you may not get all of the answers up front. You may not have a doctor that says, “Oh, this is what’s wrong with you and this is what we need to do.”
So I think that was something I got a sense of. Sometimes it was very clear cut, sometimes the doctor said, “Okay, here’s the situation, here’s the emergency, here’s what we need to do to fix this patient,” and sometimes it wasn’t. I think that what I came to appreciate was the fact that patience often works on the side of the patient. Sometimes the doctor would say, “Let’s take a day if you can afford it or let’s take a day or two. Let’s observe, let’s see what’s happening. Let’s see how this person progresses before we decide exactly what’s best.” So, I think that was something I probably didn’t realize was happening either.
Kotz: Really, get as much information as you can from the doctor. Ask the doctor if you can see your chart; you can read your chart at any time. In other words, be an active part of the process, and also have somebody come with you as well who can be supportive, because often, especially with serious illnesses, the minute the diagnosis is given, the minute the doctor starts talking to you, you just hear white noise and can’t hear anything else. Having that person with you in the room who can really listen to what the doctor is saying is helpful so that later on you can ask questions, because you may not think of all the questions you need to ask right away.
That is something I learned from the doctors at Maryland; they tell me that it’s not just one conversation that they’re having with the patient, it’s often several conversations over many weeks or many months, especially for patients with chronic diseases that often need multiple treatments, coming into the hospital multiple times. These treatment options may change if something progresses or something gets better, so the dialogue should really be continuing. You shouldn’t just be expecting to meet the doctor, have them introduce themselves, and have one conversation; you should really be having a sort of ongoing conversation.
Kotz: I hope it prepares them a little better for when they’re in these situations. I certainly couldn’t outline every possible scenario that patients may face, but I’m hoping that, by reading the story, people understand that some of these decisions are often really tough. Often there’s not enough science to back up a treatment plan either way. But I’m also hoping they understand that, as an individual patient, there may be factors that they need to bring -- personal factors -- into these decisions. So, whether they have a young child or what quality of life they’re expecting for themselves -- do they want more quality of life or quantity of life? What are the kinds of things that they personally want in their world as much as possible? We all would like to live as long a life as possible in the best health possible, but we don’t usually have those choices, so to really think about what it is that’s their first priority when it comes to medical care. What do they want out of this particular procedure? If they have to have certain things that are taken away from them – certain trade-offs – what are the things they’re willing to give up and what are the things they’re not willing to give up?
Kotz: It definitely shed light on how doctors and patients are making these tough decisions every day. I think that people should aim to be proactive patients, to engage the doctor in dialogue to be able to address any of their concerns and any of their questions. This can really help them make the most informed medical decisions that they can.