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Emily Silverman

Sometimes the hospital gets busy. Way too busy. Let's say you have 12 patients, and then you get paged about two more, and then another two and then another two, and you're sleep deprived and overwhelmed and struggling to manage. What do you do? This is The Nocturnists: Stories From the World of Medicine. I'm Emily Silverman. Today we hear a story from Abhi Kole about the ethics and the art of blocking patients.

Abhi Kole

I think that under times of stress, the ideals break down.

Emily Silverman

Afterward, Abhi and I talk about how many patients is the right number for one doctor to take care of? And what are the emotional barriers that come up when it's time to ask for help? Here's Abhi.

Abhi Kole

Every doctor at some point in their lives has written or said the words "Because I want to help people." Whether it was in our personal statements or residency application job interview, we've all said it. What I never anticipated was that one day, I would have to qualify that statement. "I want to help people, just not too many people." Like, when I was evaluating a patient in the ER that was struggling to breathe, but at the same time, another one of my patients is having a heart attack on the floor. And I don't know which one to go to.One night, I was admitting, and I was called to see three patients in the span of two hours. I was pretty busy, but I had seen them all. And I was writing my notes furiously on the computer before I got called about the fourth one. When I see one of the residents, a year ahead of me, walk into the resident room and he's looking far too relaxed. So, I say, "Hey, Jason, are - aren't you also three admissions in? How are you finished with all your work so quickly?"And he looks at me and says, "Nah, man. None of those admissions were appropriate for medicine. So, I told the ER we weren't going to take them." "Wait, what?" What black magic was this? You're telling me that I don't have to admit everyone I'm called about? And that's when I learned about blocking. Blocking is when a patient is assigned to your care, but you decline them.And blocking can be done for a variety of well meaning reasons, like maybe the patient is too sick for your service and should actually go to a higher level of care. Or, maybe their problem is surgical, and I'm a medical doctor, I'm an internist. So, they should really go to a surgeon and not me. Or, maybe they're not sick enough to be in the hospital at all. For example, I was once asked to admit a patient with high blood pressure. It's not uncommon, but I looked through his chart and I didn't see anything, any red flags, so I didn't think he needed to be in the hospital per se.So, I walked down to the ER, I find the attendings room and I very shyly peek my head in and say "Hey, so I'm seeing Mr. So-and-so with the high blood pressure. I can see that it's, it is pretty high but I actually don't think he's at risk of having a stroke or a heart attack or anything bad like that. So, I was just gonna start them on some medicine, send him home. What do you think of that?" And much to my surprise, the attending says "Okay." So, I'm thinking wow, this was easy. And, and I just saved this man a hospitalization. Everybody wins.And blocking became a culture, so... And people that were good at it were idolized. Like my friend Jason, for example. He was so good at blocking that we had printed out a picture of him, put the words "the art of the block" above his face, and made it - I photoshoped it to look like Donald Trump's art of the deal. And this, this hung up in the resident room as like, an inspiration to the rest of us.But as I'm about to tell you, blocking doesn't always mean well. And if done for the wrong reasons it can lead to patient harm. So , I have to tell you a little bit about the hospital where I trained. I trained at a county hospital. It was underserved and overcrowded. The kind of hospital where the hallways of the ER were always lined with patient beds, because the rooms were full. When we were in a crunch, we would convert the family waiting areas into extra patient beds, or extra patient rooms with beds.And like, if I wanted a bag of Cheetos, I would have to go by five patient beds that were separated by curtains just to get to the vending machine. And at it's very worst, which was the flu season of 2018, if anyone remembers last year, the hospital actually set up a circus-sized tent outside of the ER to accommodate the extra volume. Mind you, they did not hire any extra nurses or doctors to take care of those patients that got admitted. But, they were proud of this nonetheless and we made the local news.The reason this hospital was so crowded was because we were a safety net, meaning that we rarely turn patients away. And what this meant for the doctors that work there was that our limit to the number of patients we could see was often higher than it would be at other hospitals. And in the case of the ICU, it was non-existent. During that flu season, the ICU had 40 patients in it. The ICU only has 20 beds. So, half the patients were still in the ER or scattered throughout the hospital. And overnight, there's one resident that's responsible for managing all of those patients, supervising two interns, and taking new admissions. It was a Herculean task.For every patient that we stabilized, we will get called about two more. When I was the ICU resident, I got a call one day from one of the medicine teams about a patient that they thought needed to be transferred. He was an 87 year old man, his name was Mr. Jones. He came in with a urinary tract infection. Today, he's acting very differently than when he first came in. He doesn't remember his name anymore, he's pulling out his IVs, even hitting the nurses. And we measured a lactate, which is a blood test that goes up when different organs of the body don't get enough oxygen. A normal value is two and his was six. Mr. Jones was sick.But, I looked up at the clock and I saw that it was 4pm. And I'm not even halfway into my 24 hour shift. And without a limit on to the number of patients I could take care of, I was very anxious about what that night held in store for me. And then, I thought Mr. Jones has a medical team already and they have fewer sick patients than I do. And they're a really good medical team, because they've already given him the fluid and antibiotics I would have recommended anyway. So, I blocked him.But, I left my phone number in the whiteboard in his room and told the nurses to give me a call if anything had changed. So, I go back to the ICU and I start answering the long list of pages that I've been ignoring. Mr. White; he's breathing way too fast, so I need to adjust his ventilator. Miss Brown just threw up blood again, so I have to measure her hemoglobin and see if she needs another blood transfusion. And Mr. Reese just had a feeding tube placed, did I want to check an X-ray to make sure it was in the right spot before I start using it?I'm working my way through this list when my cell phone goes off. It's Mr. Jones's nurse. He's calling me to tell me that his blood pressure has dropped. So, I rushed back to his room, and on the monitor staring back at me very ominously are the numbers 70 over 50. I'm freaking out, because this is a lot lower than his blood pressure was just a few hours ago. But, I look at the clock again. There's still 12 hours left in my shift. And now I'm even more overwhelmed than I was before. So this time, I think to myself, maybe that blood pressure isn't real. He has an irregular heart rhythm. So, the blood pressure cuff might not be working, might not be picking it up.So, I put in an invasive line into one of his arteries for continuous blood pressure monitoring. And this line does confirm that his blood pressure is 70 over 50. And on top of that, his repeat lactate comes back even higher than it was the first time. So, there's no denying it at this point. Mr. Jones wasn't going to get better with the fluid and the antibiotics like I had hoped. So, I brought him to the ICU. I started him on some medications to keep his blood pressure up. Overnight, he pulled out his IV again.This time, I put in a larger one into one of his neck veins and sewed it into place, but he kept getting worse. And by morning his, his family asked me to stop doing invasive things to him and just focus on his comfort. Mr. Jones passed away just a few hours after that. At this point, I had two emotions. One was relief that the night was over, but the second one was guilt. Would things have been different if if I brought Mr. Jones to the ICU sooner? Did I block him out of selfish reasons to protect myself and my interns from an unsafe number of patients?And then, I thought back to that personal statement I had written so many years ago, where I said that I just wanted to help people. But, here I was doing everything I possibly could to avoid helping him, to avoid taking responsibility for him. When did I stop seeing people as people to be helped, and start seeing them as patients to be blocked And I felt like the caring person that I knew was still inside me was supplanted by exhaustion and self-preservation. That I was part of an unfeeling wheel that was prioritizing volume over compassion or humanity.So I thought, again, about that family meeting that morning. Mr. Jones was surrounded by his wife, three daughters, two grandchildren. We all sat around in a circle around his bed. And after they made that decision to transition to comfort care, they started exchanging stories about him. One of the grandchildren piped up and was like, "Remember when Pappy ate that entire watermelon at the picnic last summer, because I bet him he couldn't?" And her mom said, "Yeah, that was the Korea in him. No one's gonna tell him what to do."And they keep going, and they keep telling stories, laughter through the tears. And I quietly leave the room. And I think to myself, what else have I missed? What else don't I know about Mr. Jones? He has 87 years of stories, and all I know about him is that he had a urinary tract infection. But, I will never know. Because, I practice medicine in a broken system, where I was too busy convincing myself that he wasn't even my patient.

Emily Silverman

All right, so I'm sitting here with Abhi Kole. Thanks so much for coming in, Abhi.

Abhi Kole

Thank you. It's a pleasure to be here.

Emily Silverman

So Abhi, you just got back from India. Tell us, what were you doing in India and why were you doing it?

Abhi Kole

Sure. I am a heel fellow. It's a fellowship that emphasizes health equity. And I was working in a state called Chhattisgarh in rural India. And actually, after doing the India stint, I, I want to continue working with underserved populations. But, I've decided I'm going to do it in the US. And I'm currently applying for jobs looking at county hospitals exclusively.

Emily Silverman

So, you're staying in the fire?

Abhi Kole

Yep, absolutely.

Emily Silverman

I want to bring us into your story a little bit. And it seems like one of the central themes of your story is this fundamental tension between the quantity of patients and the quality of the care that's provided. And so I'm wondering, as you went through your residency, did you develop any thoughts about like, how many patients is safe for one doctor to take care of?

Abhi Kole

When I started residency, the cap that we had for the general medicine floor was each intern could have 10 patients. And I found it to be safe. And then, in my second year, that cap lowered to eight patients per intern. And at first, I was wondering, is this really necessary? But, what I realized with having a lower cap is that it allowed for more time to do teaching. And I think, being at an academic center, that's very important that we are able to balance the teaching with the patient care.So, I – now I think that eight patients per intern is the right number. It also depends on which hospital you're at. Because in India, for example, the game was played with completely different rules. And I was taking care of over 20 patients a day on my own. So, I do think it depends on which hospital you're out and what the nature of the patients are that, that come there.

Emily Silverman

I think that's so true. Because at my hospital, a lot of the patients come in with a mental illness, substance use disorders, psychosis, behavioral issues, acting out... Nurse will page and say, you know, "This patient is running around the hallway, can you come and help calm them down?" And all of these different things that really take up time in the day. And I think also, it depends on how well you know the patient. So, that friction point of having to get to know someone really rapidly increases the exertion, whereas if you already know the patients really well, taking care of more patients may be more feasible. Wouldn't you agree?

Abhi Kole

I do. I think that this also comes into play for continuity of providers. So, if you're on service for five days, and by the fifth day, you know most of your patients, it's a lot easier to see them in the morning. You know their history, you know what needs to be done. Whereas on the very first day, when you're meeting all of your patients for the first time, it's naturally going to be a longer day, and it's going to take more time. So, I think that reducing provider handoff, or, or providers doing several days at a time in longer stretches, can also help with, with easing that burden.

Emily Silverman

Definitely, continuity is important. But, you also have to balance that with the burnout of working, you know, 10, or 14 days in a row, because I've done that too. And on day 14, I'm not as good a doctor as I am on day one. The other thing I was thinking about is how medicine is so unpredictable. You can have a really quiet night in the hospital where like, it's mellow, everyone's fine, nothing's happening.Or, you can have a night in the hospital where shit hits the fan and everyone's getting sick, and everyone's bleeding and everyone's having heart attacks. And you're running around and two people is like, nowhere near enough. And so it's like, how do you predict how many people you're even going to need when you don't know how sick the people are going to be? And how many new patients are going to flow through the emergency room in that day?

Abhi Kole

I think that's a really good point, because that is what happened to me during my story. If your patient population doubles, then really your time gets cut in half. And that's a finite resource that, that now you just have less of. And so, are you really able to provide the same standard of care that's expected when you have half of such an important resource? What's important, I think, is to have a contingency plan, so that you're prepared for the worst case scenario, but not necessarily have to use it. So, having some doctors that are on call, or as we call it Jeopardy, if needed, they - they're brought in... And to use that to keep the ratio of providers to patients relatively stable.

Emily Silverman

But how do you feel like we're doing as a healthcare system with this? Like, I'd love to think that every clinic and every hospital has these sort of people in the wings waiting to be called in if the census skyrockets. But, my sense is that it seems like everybody feels overworked all the time.

Abhi Kole

I've talked to several attendings that are more senior than me, and I think the impression that I'm getting is that medicine is changing, in - more recently, in the last decade or so. And patients are using healthcare a lot more. And we have a influx of not only number of patients, but the complexity of patients that are coming in. There's just a lot more possible now than was possible 30 or 40 years ago.And so, the patients that come in are pretty complicated and or have a lot of procedures done, which we might be learning for the very first time. And, but we're still staffing hospitals in a model that was present from 30 or 40 years ago. And so, I think we need to be cognizant of maybe having lower caps and having a higher provider to patient ratio now than we did in the past, just because the patients are more complex.

Emily Silverman

Yeah. I just read this really interesting article in the Journal of Hospital Medicine, I think it was. And one of the authors was this Dr. Alan Detsky in Canada, and it's - it comes in two parts. And it's night call in 1979. And it's night call in 2019. And in 1979, he describes the night call. And basically, there were pagers, but they almost never went off, because there was really no computers. So, everything was done face to face through conversation, and so there was no like, constant cognitive interruption.You would just come in and be face to face with the patients and the nurses. And the pager would only go off if there was an emergency or if you had a new patient. And he talks about how the whole team would have dinner together at 10pm. There was a social component. But, the part that was the most striking to me was he said there were about 20 medicines that he had in his toolbox. It was like a beta blocker, a biocide, an aspirin... Was like colchicine, you know, some like old school stuff, I think.And it really made me think that in 2019, we have these constant cognitive interruptions. But, there's also just so many different, more medications that we have at our disposal to prescribe. Not to mention, like you said procedures, pacemakers, dialysis, all of these different things. Like, medicine is just so much more complex than it used to be. And so, should that factor in to hospital staffing models?

Abhi Kole

I absolutely think it should factor into hospital staffing models. And with all the technology that we have available nowadays, which is great that we're able to provide this much care to patients. It means that the legwork required to learn about a patient is also much higher, and so that takes a lot of time. And I don't think we appreciate how much time that takes to fully learn about a patient.

Emily Silverman

I think that's so true. When a patient comes into the hospital, and it's you know, middle-aged person who has had a kidney transplant, and they're on all of these different immunosuppressants... And you have to go back in time and understand like, what was the cause of their renal failure? When did they have the transplant? When did they go on the drugs? When did they go off and then back on, and then off and back on?And I've seen the rheumatologist even put together these like, diagrams where it's like, okay, from this year to this year, the person was on rituximab. And then, from this year to this year, they switch to this other like, TNF alpha inhibitor, you know? And they're just like, mapping out... The histories are just incredibly dense and complex. And so, how do you give yourself the time to process all of that?

Abhi Kole

If a patient is showing up to seek health care for the very first time, that's actually almost easier. Because then, you don't have pages and pages of material to read from, from a different hospital or a different provider. And you don't have to scroll through the chart and figure out what happened to them in the years before you're taking care of them.

Emily Silverman

That moment when the deep, deep medical chart actually starts to feel more like a liability than a blessing. Like, I've had patients who hit the door at the general and it's like a 65 year old man who has been out of medical care for his whole life, coming in with a new diagnosis of diabetes, or whatever it is. And the truth is, that's actually tragic that this person has not been plugged into care.

Emily Silverman

But there's definitely this like, wave of relief that I feel when it's like, oh, thank God, I don't have to sift through 36 discharge summaries to get a picture of what is going on with this person. I can just start from scratch. And there's sort of like a blissful ease to that, wouldn't you say?

Abhi Kole

Yes, I do think that that's true. And that's another difference that I noticed practicing in India versus here. Because in India, you did have a lot of the patients that would come to the doctor for the very first time. And they weren't medically uncomplicated. Some of them had very complicated diseases like nephrotic syndrome. And they would come in completely swollen up, because they were losing so much protein in their urine. But they weren't as complicated to think about in the moment.Because in India, I didn't have access to kidney biopsies, we didn't have all the fancy labs that we have here... And so, the plan was very simple. Like, I would have to give them steroids and see if they respond. Or, I would give them lasix and get the fluid off. It's a double edged sword, because this patient with nephrotic syndrome would definitely have received better care if I did have all the information. But at the same time, it also would have taken a lot more time and effort, and resources and...Would those resources be better used for - to just to see more patients? In India, that's probably true, it probably would be helpful just to see a higher volume. Here in the US, I think that given all the resources we do have available to us, I think it makes sense to use those resources to learn the most we can about our patients and provide them with the highest level of care possible.

Emily Silverman

You know, one of the things is when you're dealing with these high numbers, and you're wanting to protect yourself and protect your team, that's when this practice of blocking happens. And you joke about your colleague who was an amazing blocker, and 'the art of the block' and all these things. So I was wondering, what does it take to be good at the block?

Abhi Kole

I think the best blockers are the ones that can offer an alternative. So, you could say, "I don't think this patient belongs on the medicine service. But, here's an alternative plan." So that, you can give the other physician some sort of indication that you've thought about this patient and you're not just deflecting. And so, maybe we're not actually blocking the patient, but we're triaging them to a more appropriate service. And whether that be going to a surgery team, or going to the ICU versus the floor, or maybe even going home... If they don't need to be in the hospital and being in the hospital would actually be more risky than, than treating them at home.

Emily Silverman

One of the things I loved about your story is you describe this sort of sinister warping of the blocking decision-making where it stops becoming retriaging. And it starts to become a defense mechanism. Like, I cannot take any more patients. Like, who can I block? Who can I shift elsewhere? But I'm wondering, how do you think about that line?

Abhi Kole

I think that under times of stress, the ideals break down. And it doesn't come from a bad place necessarily, I don't think that it makes me a bad doctor. I think what it makes me is someone that wants to give the best care I have to the patients I already have. And knowing my limits, knowing that taking another patient would reduce the level of care for everybody else. And I think that what we need to do is make it acceptable for doctors to say that I've reached my limit, I need help.It shows that we're able to put our egos aside for the sake of a patient. And I think in the medical profession, were not very good at admitting that we need help. That we need to call in somebody else from home. Like I, every time I needed to call the ICU fellow, I felt terrible about having to call somebody and waking them up and having them come in from home.

Emily Silverman

Like, you felt like a nuisance. Like, I've just had that feeling so many times. I mean, is that on me, and you and us? Or, is there something we can do from a broader cultural standpoint to reduce that feeling of guilt? Or, like ugh, I'm dragging this person in... How do we think about that?

Abhi Kole

I think it's a difficult question to answer, because if it's their job, then we shouldn't feel guilty about asking people to do their job. But I think underneath, we probably have the sense that their job is also unfair. And so, we feel guilty about making them do it. Maybe if we were to devise a system where if someone is called in from backup, then they get paid for their extra work, that might make us feel less guilty. Or, if there were several people on Jeopardy, and and it rotated through who would get called in, that would also help. And that is actually what my residency program did, is that we had four people on Jeopardy at a time, and it just rotated who would get called in, so it wouldn't be the same person every time.Emily Silverman
Or, devise a system where the person who's on backup call, you don't feel so badly because you know that you're not cutting into like, the only time that they have to spend with their families and to tend to their own personal health needs, mental health needs, rest, and so on and so forth.

Abhi Kole

Yeah, and I wanted to share like, an epilogue of what happened after this story. I did go to my program director with some of my concerns about the provider to patient ratio in the ICUs. And even though it didn't happen during my month in the ICU, a couple months later, there were new caps put on the ICU resident. And then, an ICU fellow was called in if the cap was exceeded, or they would call in additional providers to provide independent care.So, I think that change is possible. It requires your voice to be heard and for, for people to actually speak up. And I was fortunate enough to go to a residency program where the program director was open to hearing feedback from the residents about how to improve systems. So, I was very grateful for that as well. And that's the part that didn't make it into my story.

Emily Silverman

And I am so grateful that you felt brave enough to come on stage and share that story. Because it's not an easy story to share. But, I think so many people in the audience connected to you in that moment, because we've all been in that moment, where we get called about another admission and this feeling washes over you and you're just like, "Oh my God, how many more can I take?" So, I thought that was a really important topic to bring to the floor. And so, thank you so much for coming to share it on The Nocturnists stage.

Abhi Kole

Sure, you're welcome. I had a great time.

Emily Silverman

Thank you for being part of The Nocturnists' community.