April 5th, 2007 by Dr. Val Jones in Opinion
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I had dinner with a small group of people recently – and Harvey Fineberg, President of the Institute of Medicine, was our dinner speaker. A few things struck me as he reviewed the history of this 37 year old institution.
First of all, The British Medical Journal published a thought-provoking article about the top 5 things that Britain and the US could learn from one another’s healthcare systems. Of all the possible things that they could highlight about US Healthcare, the Institute of Medicine was listed in the #1 slot.
Well, my goodness – is that the very best of what US medicine has to offer? The IOM?
Maybe so. Here’s the Reader’s Digest version (forgive me Dr. Fineberg) of the history and purpose of the IOM.
President Lincoln founded the National Academy of Sciences back in 1863 for the purpose of advising the public in an objective manner on matters of science. The NAS has expanded to include 3 newer organizations: the National Research Council (1916), the National Academy of Engineering (1964), and the Institute of Medicine (1970).
The IOM consists of members elected by peers in recognition of distinguished achievement in their respective fields. It has about 1,200 members. But here’s why this organization is so unique: all of the members VOLUNTEER their time! Can you imagine another organization that could get 1,200 doctors to work for free? Yes, they volunteer – and they do so gladly because it is an honor to be part of the task force to advise the public in an objective manner on matters of medicine. The IOM gets no money from the government, it survives on donations and volunteerism.
The IOM is uniquely positioned to formulate unbiased assessments of important medical questions. It is medicine in its purest form – the facts and the data are the only foundation of their analyses. No government funding, no pharmaceutical intervention, no personal agendas. Just the pursuit of truth.
Apparently the IOM produces 1 report per week! The most famous of which may be their “To Err Is Human” (2000) report which uncovered the shocking frequency of medical errors, and included recommendations for new patient safety initiatives.
A lesser known report actually debunked lie detector tests…
And so, as I considered Dr. Fineberg’s description of the IOM I began to realize why other industrialized nations are jealous of our institute. I am so glad that President Lincoln had the foresight to create an objective, “collective wisdom” vehicle for advising the nation. The question now becomes: does the nation hear what they’re saying?
I think it would be wonderful for the IOM to allow Revolution Health to be an outlet for disseminating their information to the public. After all, our mission is to empower consumers with the most credible health information available… and my friends, after hearing Dr. Fineberg’s speech, I don’t think it gets any better than the IOM.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 4th, 2007 by Dr. Val Jones in True Stories
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My parents are strong believers in the idea of purposeful exercise. They couldn’t imagine working out in a gym, laboring on a treadmill with nothing accomplished at the end beyond sweating. No, for them, activity is critical – but it has to result in a tangible, quantifiable product.
And so it may come as no surprise that they left Manhattan in the early 70’s to raise their kids on a farm in Canada, where we were kept very busy herding cows, lifting milk crates, feeding pigs, fishing on the nearby ocean, and weeding our very large organic garden.
But as Manhattanites, my parents made sure that I read the New Yorker (we grew up with Calvin Trillin’s children), attended summer school in Paris and ski camp in Switzerland. We took a family vacation each winter to some tropical island, where I played with vacationing city kids.
But this strange combination of “country mouse, town mouse” occasionally produced some rather bizarre traditions – my favorite of which is the annual, December “Easter egg hunt.”
My parents would take us to a rather exclusive golf course on one of our vacation islands, sign up for a round in the late afternoon when most golfers were finishing up, then find us an empty bucket for golf balls. Then we’d walk off in the direction of the 9th hole, and my mom would tell us that there were golf ball “Easter eggs” hidden in the rough patches around the golf course, and that it was our job to fill up the bucket with as many balls as we could find. For young kids, I can tell you, such a challenging and large Easter egg hunt was really exciting.
So I searched fairly systematically through all the patches of rough, proudly announcing each new egg that I had uncovered: “Mom, I found one!” I’d beam, “and this one is bright orange!”
My younger sister wasn’t as successful at locating golf ball eggs. She tended to try to pick them off the fairway, where they were sitting targets. Of course my parents would have to reel her back in, explaining that the Easter eggs were only hidden in the deeper grass.
And we would spend hours and hours on our Easter egg hunts, until the sun set and the crickets drowned out the sound of the ocean waves. We often found an annoyed golf course crew waiting for us to return so they could close their pro-shop. My sister would hand them a bucket brimming with golf balls, saying “we found all these Easter eggs!” And the cuteness of her innocent glee would melt their annoyance as they put the bucket behind the counter, eyeing my parents suspiciously.
But those were good times – where exercise was effortless and fun. Where a common goal drove an entire family to activity, and kids maintained interest in something beyond the TV set.
Now as the real Easter approaches, I imagine what it would be like to return to my childhood activities at a local golf course. I suspect that my physician colleagues would frown upon me collecting stray golf balls at their respective courses. But to tell you the truth, I think that would be more fun than actually playing a round, don’t you?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 2nd, 2007 by Dr. Val Jones in True Stories
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Continuing on with the car accident theme… A patient came to see me in the clinic. She had been run down by a bike messenger (could it have been my friend with the bleeding leg?) when attempting to step out of a bus onto a cement curb. She had a lot of pain in her shoulder and side, and was taken to the ER where a chest XRay was unremarkable. She was released with a prescription for extra strength Tylenol.
Still in pain, she made an appointment at the hospital’s orthopedic clinic for the next available time slot (she was covered by Medicaid) where she met with a young resident who suspected that she was a drug seeker and sent her away with “reassurance” and more Tylenol.
The woman, knowing that if she came back to the clinic again, she’d probably see a different physician (and could therefore get a second opinion) – made another appointment. The next orthopedic resident read her chart (where the previous resident had written that the patient exhibited drug seeking behavior) and barely listened to the woman’s story. But after the patient insisted he do something, the orthopedist did what most do with “chronic pain patients” – send them to the rehab doc.
And so, nearly 6 weeks after the accident, I met the woman in the rehab clinic. I had read the ortho notes prior to seeing the patients and was nearly convinced from their descriptions that she was a belligerent, drug-seeking nightmare.
The woman was thin and irritable. I asked her why she had come to see me, and she said she thought I was going to do some physical therapy with her. I asked if she could recount the events in her own words, and explain what exactly was troubling her. As the story unfolded, I was saddened by what she described – the endless frustration of being in pain, of being bounced around from one young physician to another in clinics overflowing with patients, and of being labeled as a drug seeker. And all this after a very painful encounter with a hit-and-run bike messenger.
I asked her to describe her pain and point to it exactly. She said it had been slowly improving, but that it hurt most when she breathed in and there was some point tenderness over her 8th, 9th, and 10th ribs. I asked her if she had had a rib series… nope just a chest XRay.
I told the woman I thought it was likely that she had fractured her ribs, and that rib fractures are often hard to see on XRays, especially chest XRays. I also told her that there wasn’t any real treatment for rib fractures, except pain management and time to heal. Her face lit up.
“So you believe me? I’m not crazy?”
“Sure I believe you,” I said. “I’ve fractured ribs in the past and I know how painful it is. When it happened to me no one believed me either. My chest XRay was normal.”
“So what did you do about it,” the patient asked, looking at me compassionately.
“The truth is, I had to sleep sitting up for a week or so, and I breathed very shallowly for a while. Eventually, though, the pain went away on its own.”
“Thank you for listening to me, doc,” she said, tears welling up in her eyes. “Even though there’s nothing I can do about the ribs, I’m glad to know what the pain is from, and that I’m not crazy.”
I wrote a short note in the chart, documenting my impressions. I did not recommend physical therapy for the patient, but to follow up if needed.
Apparently, the woman had one more clinic appointment with the orthopedic team. They read my note and ordered a rib series to confirm the diagnosis. The rib series showed healing fractures of ribs 8, 9, and 10.
I never saw the patient again, but I’m quite sure that explaining her diagnosis was the most therapeutic thing that we did for her.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 1st, 2007 by Dr. Val Jones in True Stories
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A few years ago I was walking home from the hospital after a long shift, when I witnessed a bicycle messenger struck by a taxi cab. The cyclist was riding at high speed across a crowded intersection and the cabbie was accelerating through a stale yellow light. THUD. The man flew across the pavement, the cabbie screeched to a halt, horns honked, a crowd gathered… I ran up to the man to check him out. His right shin was bleeding (he was wearing shorts), but I didn’t see any obvious deformities or broken bones.
The man was panting, his adrenaline pumping. I asked him to stay down for a moment while I checked him out. “F-off,” he snarled, “I don’t need your help.” Since I saw him fall, I knew that he hadn’t sustained a head injury that could explain his potential disorientation and poor decision making. I called 911 on my cell phone and gave them the scene coordinates while I tried to get the man to agree to get checked out. “I don’t need a f-ing ambulance, don’t call them!” he screamed, blood dripping down his leg. I did my best to reassure him, but he was adamant. He got up and started limping towards his bike (which, quite miraculously, was not bent out of shape from the blow). I continued to plead with him to just wait a moment to let the paramedics take a look at him, but he would not be detained. Short of using brute force to keep him down, there was nothing I could do. Distant sirens sounded, he hopped on his bike, muttered “I don’t have insurance” under his breath, and rode off. The taxi driver appeared extremely relieved. The crowd dispersed, the taxi left the scene.
When the fire truck arrived, I explained the situation. They asked which direction he’d driven off in, and they pursued. I don’t know if they ever found him, but catching a cyclist with a fire truck on the crowded streets of Manhattan is unlikely.
——–
A few weeks ago I was walking down a narrow street in DC. An ambulance was parked in the middle of the street, a small SUV was in front of it, and a middle aged woman in a dark suit was sitting on the asphalt appearing angry but unharmed. I heard from an onlooker that she had darted out behind the SUV while it was moving slowly in reverse. She had been struck lightly, but was speaking loudly about suing the driver, and was demanding that she be taken to the ER for a full check up. The EMS team interviewing her was hesitant to put her on a stretcher since it was so obvious that she could walk. The woman was refusing to get up, and they were trying to figure out how best to carry her.
I gritted my teeth and walked away, wondering what kind of legal torture the SUV driver was in for.
These two car accidents left an impression on me – the uninsured will go to extremes to avoid costly medical care, while the personal injury lawyers rack up serious cash on trumped up claims. What’s the point of this post? I guess it’s a reminder to look both ways before you cross the street, drive carefully to avoid pedestrians, and make health insurance a priority!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 1st, 2007 by Dr. Val Jones in Medblogger Shout Outs
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In a really engaging recent post, ER doc Edwin Leap (via GruntDoc) discusses why it seems that the general public is outraged at reports of the occasional specialist who makes $500,000 and yet do not flinch at the much larger salaries of football players, musicians, or media tycoons.
I posted a response to Dr. Leap’s blog post, explaining my take on why people are so angry. Let me know if you agree:
You are right that there is a lot of anger towards physicians – it is the collateral damage of the broken physician-patient relationship. When third parties (insurers) got between us, and reimbursement dwindled with drastic cuts in Medicare/Medicaid, physicians had to make up the difference in volume. When you see 30+ patients/day none of them feels as if they’ve had a valuable interaction with you. And the physician’s memory of each individual patient (and their psycho-social context) becomes dim.
When we lose the sacred, personal, physician patient relationship – we lose the best of what compassionate individualized medical care has to offer. This is why patients believe that a government sponsored system can give them the same level of care that they currently receive. I shudder at the idea of handing over medical decision making to a distant bureaucracy that only knows what’s right for a population, not for the individual. But if doctors continue to treat patients like a commodity, the patients are actually receiving nothing more than population-based care anyway. Quality care is personal, and the physician-patient relationship is a trusted bond that cannot be easily broken. We need to know our patients well so that we help them to make the best possible decisions for their personal situation. I believe that the IMP movement (see Gordon Moore’s work) – where PCPs use IT to drastically reduce overhead costs so they can afford to see fewer patients – is one of the best ways to improve healthcare quality.
As far as Emergency Medicine is concerned – we need to get the non-sick patients out of the ER and back to the PCPs. Easier said than done – but if the patients have a real relationship with their PCPs they’re less likely to substitute an ER doc inappropriately.
My 2 cents! 🙂
Patients are angry about physician salaries because they know instinctively that they are not getting the quality care that they are paying so much for… Moreover, the major cost causers (hospitals that cost shift unpaid bills to the uninsured and take large cuts for hospital administrator salaries, and for-profit insurance companies) don’t have a name and a face to the patient. So docs take a double dose of anger on the nose, further damaging the already strained relationship. We must go back to our roots – and support the personal doctor patient relationship that has been a pillar of American medicine. Revolution Health can be our meeting place… the new digital medical home, supporting the old physician-patient team decision-making approach!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
