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A “Third Place” In Healthcare: What We Can Learn From Starbucks

Media reports on misdiagnosis continue to mount. A recent study on patients with Alzheimer’s found that half had been misdiagnosed. Half.

Another headline blared “4 out of 10 patients being misdiagnosed.” The article encouraged patients to “see another doctor” if they are worried about their diagnosis.

You know what it makes me think about? Starbucks. Why? Because the way Starbucks revolutionized coffee drinking shows a way forward for healthcare.

Starbucks realized that since our lives focus on two places — home and work — most of us don’t have a “third place” to go. A place where we can be free of everyday distractions and take care of ourselves. Starbucks set out to create that “third place” by making its shops comfortable, inviting places. It works. “Third place” makes customers’ lives better — and Starbucks has almost 20,000 shops to prove it.

It’s time for a kind of “third place” in healthcare. Healthcare focuses on two places, too: The doctor’s office and the hospital. Both places are difficult for patients. Patients complain of not getting enough time from their overworked doctors, and studies of things that go wrong in hospitals are equally disturbing.

There really isn’t a “third place” to go to in healthcare. Somewhere that you can step outside of the difficult process of being sick. Somewhere you can get a quiet, clear perspective of what is going on.

Now, some people are lucky and can turn to relatives or friends who are doctors to provide some of that “third place” experience. But most people can’t. At Best Doctors, we’re creating the experience of a healthcare “third place.” We do it by taking the time to review each case, have doctors think about what’s happening, consult with experts, and share advice. Read more »

*This blog post was originally published at See First Blog*

Making Employee Health A Fundamental Part Of Company Culture

Dick Quinn of Quinn’s Commentary has a pithy post about why it’s hard for the government to control healthcare costs. He says:

Nobody complains about the cost of healthcare, rather they complain about their insurance premiums or their payroll deductions for health benefits.

He’s right about what politicians react to. The healthcare reform law is loaded with things that are meant to contain the price of coverage. But I would add two words to his post:

“Nobody who votes complains about the cost of healthcare.”

It’s true: The large employers who pay for much of healthcare in America complain about the cost a lot. But they are doing something about it.

In my work, I have the opportunity to present at events with some of our Fortune 500 clients. (I have one this week with The Home Depot, hosted by the National Business Group on Health. The event information here – you have to be a member of the NBGH to participate). Listening to these customers, you get a good sense of how employers are attacking this problem.

Here are the top three trends I see benefits professionals talking about:

1.  Engagement and Prevention

Doing things to help employees be enthusiastic believers in their company is high on the list of many companies’ strategic objectives. Employee benefits are an important part of that.

A senior benefits leader at a Fortune 100 employer I presented with earlier this year said his company surveyed its employees to see what they wanted in their benefits package. Number 1? That the company’s  benefits show it really cares about their well-being. Benefits professionals see health benefits as an opportunity to engage employees in their jobs. Read more »

*This blog post was originally published at See First Blog*

A Doctor’s Brain: The Most Important Piece Of Healthcare Technology

Some people may tell you that healthcare IT will solve many of the quality and cost problems in healthcare. I don’t believe them.

I know a 70-year old man named Carlos (not his real name) who was hospitalized following a bout of hydrocephalus. Hydrocephalus is a build-up of fluid in the skull, which affects the brain. Among other things, people with hydrocephalus can be confused, irritable, and nauseous. Carlos had all of these symptoms.

Carlos’ problem was fixable by inserting a special kind of drain in his head called a “shunt.” This kind of shunt is, essentially, a series of catheters that runs from the brain into the abdomen, and which drain the excess fluid. You can’t see it from the outside, so it’s meant to stay inside of you for a very long time.

For a week after Carlos’ shunt was installed, his symptoms completely disappeared. But they soon started to re-emerge. Worried, his family took him to the hospital. Doctors found that his hydrocephalus was back — the shunt wasn’t draining properly. They admitted him to the hospital, and the next day they put in a new shunt. The surgery went well.

But again, about a day later, he started to have the same kinds of symptoms. The doctors sent him for a CT scan, which showed, to their surprise, no problems with the shunt. Unsure of what to do, they decided to wait and see if the symptoms resolved. It was possible, they thought, that the symptoms were from the quick drainage of fluid through the shunt. Read more »

*This blog post was originally published at See First Blog*

The Worst Healthcare System In The World

The worst healthcare system in the world is the United States, of course. Oh no, wait — it’s Canada. Actually, it could be Germany. Geez, now I think it might be the UK.

You could go on and on like this, but you know what? No matter how good or bad your healthcare system is, there are certain universal truths. Here are four of them that might make you look at global healthcare a little differently:

First, healthcare is getting more expensive, all over the world. A new study by the global consultant, Towers Watson (disclosure: Towers Watson is a Best Doctors client) found that the average medical cost trend around the world will be 10.5 percent in 2011. In the advanced economies costs will rise by an average of 9.3 percent. While Americans tend to think of rising medical costs as a uniquely American problem (they’ll rise by 9.9 percent here), it’s just not true. Canadian costs will rise by 13.3 percent. In the UK and Switzerland, they will increase by 9.5 percent, and in France by 8.4 percent.

Why is it happening? As ever, the main drivers are the increasing availability of new medical therapies — and inappropriate use of care. We see the same phenomenon at Best Doctors in our global experience. Across the world, our data for 2010 showed that just over 20 percent of patients had an incorrect diagnosis, and about half were pursuing inappropriate treatment plans. Read more »

*This blog post was originally published at See First Blog*

The Secret To The Virginia Healthcare Decision

Unconstitutional? How can the mandate to buy health insurance be unconstitutional? It must be some kind of misguided resistance to progressivism. Or maybe it’s someone finally taking a stand against a power-grabbing government program.

But it’s actually about something else entirely. And if you don’t know what it is, you won’t understand why the Virginia court ruled the way it did. Here’s the secret:

The U.S. Constitution grants to the federal government certain powers. These are things like raising an army, controlling currency and establishing courts. It also gives it the power to regulate interstate commerce, through something called the “Commerce Clause.” Everything else is the domain of the states.

Notice that the Commerce Clause only gives the federal government power over interstate commerce. The word “interstate,” in 1789, was probably easy to understand. Since the original 13 states were more like little countries, than part of one big country, the idea of trading goods from one state to another was identifiable as a special kind of thing. Read more »

*This blog post was originally published at See First Blog*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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