Volume 24x No. 1x xJanuary 2000
Q: The academic divisions of respiratory medicine and critical care clinical medicine were combined in 1991 to create your department. Is it common for pulmonary and critical care to be joined together?
RUOSS: Yes, it's almost universal that the two areas are joined in academic medical centers, and its also common to have a close relationship with anesthesia.
RAFFIN: Thirty years ago, I'd say most ICUs in America were run by anesthesiologists. The change started about 20 to 30 years ago when pulmonary doctors began to be trained in critical care.
RUOSS: There are some logical reasons for this change. We've found in recent years that we can actually manage - not just palliate - patients with critical illnesses. And lung disease management is a large part of what is needed in the ICU.
Q: Your division has grown tremendously. Other than the usual explanations of good service, is there any reason that could account for a sixfold growth since 1991 in outpatient visits alone?
DOYLE: I can cite one example from my own experience with primary pulmonary hypertension. We are increasingly finding more patients we can manage without surgery with new medical solutions, including clinical trial drugs. Instead of routinely sending patients for transplant, we can now often offer medical solutions in our division.
RAFFIN: I think that's true in many areas of lung disease. With drugs we are increasingly able to find solutions instead of surgery or palliative care.
Q: What sort of patients should a physician consider referring to your clinic?
CLARK: First, we believe primary care doctors should refer patients whenever they have utilized all the basic treatments for conditions they routinely treat, such as COPD, asthma, chronic cough, sinusitis, and shortness of breath. Second, primary care doctors should refer very difficult to treat and unusual diseases routinely, such as idiopathic pulmonary fibrosis, many interstitial lung diseases, recurrent pulmonary emboli or primary pulmonary hypertension.
Q: Can you talk about some areas where faculty subspecialty expertise might be particularly useful?
RAFFIN: Steve [Ruoss] is particularly expert not only in the management of very severe asthmatics but also in atypical TB infections. This is not the regular TB you find in crowded areas or the Third World. We're finding atypical TB infections regularly in middle-aged white women.
RUOSS: This syndrome has been observed only in the past decade. Ninety percent of patients are women who show signs of a chronic and progressive infection. The organism is widespread, from the same mycobaterial family but distinct from TB, because it's not transmitted from one person to another. Patients have repeated infections even if treated. We have been trying to understand at a basic science level what subtle immune defects might play a role in the evolution of this disease, and we've been conducting clinical studies looking at treatment, outcomes and new therapies, including antibiotics. Atypical TB requires a great deal of attention. We've had a lot of experience in the level of detailed management needed, but it's still challenging - constant monitoring of side effects from antibiotics, and the results of repeated complex infections. There are even some difficulties in diagnosing the disease, but the principal difficulty is knowing it exists and recognizing it in people with relatively subtle symptoms. It's on our radar screen here, but historically it's been overlooked or when found, dismissed as a lung culture contaminant. However, it appears not to be the contaminant but rather the main infection.
Q: Where are cutting-edge drugs making or potentially making an impact?
RAFFIN: In pulmonary hypertension, Ramona Doyle and her colleagues are making significant inroads. Ramona uses intravenous prustacyclin, and we have other clinical trials for treating idiopathic pulmonary fibrosis. We have cutting-edge trials for common conditions as well. Steve Ruoss is involved in studying new drugs for the treatment of COPD and asthma.
Q: What else is new in your area?
RAFFIN: I'm particularly excited about the recruitment of Noreen Henig from the University of Washington, Seattle, for our cystic fibrosis program, both research and clinical, which traditionally has been at Packard. We have about 250 cystic fibrosis patients at Stanford, and about half of them are adults. These patients, fortunately, are living longer, so it is important to have an adult program.
Q: What steps do you take to coordinate with referring physicians?
RAFFIN: We coordinate very closely. We telephone and talk to them, and we always write letters following patient visits. The chest clinic feels strongly that it is our responsibility to maintain good communication with community physicians, and I believe that patients feel well treated in the clinic and referring physicians are happy with our feedback.
Q: How has managed care affected referrals?
CLARK: Anecdotally, I can give you an example of a primary pulmonary hypertension patient whom Dr. Doyle has been treating for almost a year from the Central Valley. The business staff at the patient's HMO wanted her to be seen nearer her home, but she really feels her best option is here, and this has required some extra effort. We're still seeing the patient here, but each visit must be approved individually by the HMO's medical director. It's touch and go until the night before whether she's going to get authorization, which is frustrating, especially when you can remember the time when patients walked in, got seen, got treated.
RAFFIN: I think some of the financial pressures on primary care doctors to limit referrals is beginning to ease off somewhat because consumers are pressuring their health plans to give them access to their physician of choice. But access continues to be a major problem. We are dealing with two misconceptions. At one extreme is the notion that helping a patient to see a specialist early will save money by reducing expensive care later. This can be true, but in the aggregate we escalate costs when we don't use some discretion about which patients are most likely to benefit. At the other end of the spectrum is the cynical idea that impeding a patient from seeing a specialist saves money. These are extremes. The reasonable approach is that patients who need to see specialists should have access to them.
Q: Tom, You have a second role as co-director of the Stanford Center for Biomedical Ethics. Do your roles ever overlap?
RAFFIN: They can be quite synergistic. Since the center is in the division, we are in an ideal position to conduct joint studies. For example, we have a study of health care rationing to cigarette smokers, and we are investigating the genetics of nicotine addiction among teen-age cigarette smokers. Furthermore, both the Center for Biomedical Ethics and the Division of Pulmonary and Critical Care Medicine deal with end-of-life decision-making, including withholding and withdrawing life support.
DOYLE: People come here for lung or heart/lung transplants because they are dying, and there is no other treatment. Our patients often face complex end-of-life ethical decisions. I teach a creative writing course and am involved in humanities programs, at least in part, because I think it fits with our mission to train physicians. Many of us believe that the old model by which we train doctors is inadequate, especially when you see how some people deal or don't deal with end-of-life or related decisions. I see humanities and ethics as part of my teaching mission and as part of my practice of medicine.
Q: In a clinical sense, what would you like to see improved?
RAFFIN: One important change we felt very strongly about has already occurred. Valet parking was reinstated in November. We were upset several months ago when valet parking was eliminated, because it seriously undermined many of our patients who have mobility problems. Another problem is that our patients find it difficult when they are sent for lab work before their appointments and must walk 40 yards away from the lab to stand in another line to get stickers for their blood drawing vials or an ECHO. In addition, we're hoping the hospital will solve its problems with dictation so that we can get a dictated letter out the door in four or five days. This continues to be a major problem.
DOYLE: Dictation is an issue that not only affects patient care, but it also affects our relationship with the community and referring physicians. If physicians send someone to "the ivory tower" and they don't hear back for two weeks, they are not going to send us any more patients. Referring physicians should never have to ask, "What happened to my patient?"
Q: At an academic medical center, how do you resolve the tremendous pressures involved with multiple missions and the need to care for patients?
RAFFIN: Our first and foremost goal is commitment to patient care. When we deliver care, we want to deliver great care. Our principle, plain and simple, is that we do not sacrifice the quality of care because of research.
DOYLE: I think the biggest conflict now is not between research and patient care but between administrative duties and patient care. If patients ever sense that you are advocating for something other than them, you've lost their confidence and their trust.
RAFFIN: One of our strategies is to carve out time for people who are strongly committed to investigation. We have two basic scientists in our division, Peter Kao and Glenn Rosen, who have 70 to 80 percent of their time scheduled to do research. So when they are in the clinic, they work very hard and they're wonderful. When they are in the lab and they're not doing clinical work, that's fine. For the faculty who are not basic scientists, it's much more difficult to find the time to develop a research career while also trying to be good doctors and to fulfill their responsibilities as outstanding teachers. That's one of the reasons I've worked very hard to increase the number of faculty members, so that there is adequate time for the faculty to be involved in clinical investigation. We're getting there. In 1991 we had three faculty members. In 1999 we had 20 faculty members.