June 16th, 2009 by MotherJonesRN in Better Health Network, Opinion
Tags: Bedside, Clinical Nursing, Nursing, Patient Care, Quality Care
3 Comments »
Do you remember this person? She is a bedside nurse. She walks up and down hospital hallways in her white nursing shoes all day long while caring for her patients. She is trained for active duty. I’m asking you this question because nursing researchers have had an epiphany. They believe that they have discovered something new in the field of bedside nursing.
Over the years I’ve observed that the more degrees and letters that a lot of academic nurses get behind their name, the more out of touch they become with bedside nursing. This came to light once again when I attended a mandatory inservice at work. I was told that we were going to talk about an innovative concept that was going to revolutionize patient care and the nursing profession. Imagine my surprise when the speaker talked about hourly rounds. Did you know that nursing researchers have discovered that patients are happiest when their nurses spend time with them at the bedside every hour, and anticipate their needs? Wow, what a concept. Academic nurses living in the ivory tower of higher learning have discovered through years of painstaking research that patients also want nurses to answer their call light promptly when they need help getting to the bathroom. Holy cow! Hourly rounds decreases the amount of time patients spend using their call lights, decreases injuries due to patient falls, and increases patient satisfaction while they are in the hospital.
Did I miss something? I remember learning all this stuff years ago when I was attending a lowly diploma nursing program. We were always walking up and down the halls in our nursing shoes. No one conducted studies on how to make patients happy back then. A little common sense goes a long ways. The formula to good patient care starts with clean bed sheets and a filled water pitcher, and ends with a connection to your patient. That’s not new. That’s nursing.
*This blog post was originally published at Nurse Ratched's Place*
June 8th, 2009 by Dr. Val Jones in Health Policy, Opinion
Tags: Abortion, Adoption, DC, Obstetrics And Gynecology, Pediatrics, Pregnancy, Washington Post
9 Comments »
The abortion “issue” is such a hot topic that I have never written about it on this blog until today. I hope I won’t regret that decision but I felt it was appropriate to respond to this medical student’s essay – and the ~560+ comments that follow it – as a physician who has witnessed (but never performed) about 100 abortions. Let me explain.
During my Emergency Medicine training I was required to perform a certain number of intubations and abdominal ultrasound scans. My residency training program offered rotations in Ob/Gyn and at a local Planned Parenthood center. The senior residents told me that the best way to fulfill my intubation requirements was to assist with the Ob/Gyn OR procedures because the patients were young, healthy, and generally uncomplicated. At the time I was really excited by the opportunity to get the experience I needed – in as short a time as possible. I used to hang out in an Ob/Gyn operating room asking if I could assist the anesthesiologist with the intubations. Once they got to know and trust me, I could intubate about 6 patients in a day – an opportunity otherwise hard to come by as all the new anesthesiology residents were vying to practice intubation themselves.
One of the Ob/Gyns who used the OR (where I got my intubation experience) scheduled some abortions of fetuses that were at the border of viable – as old as 23 weeks. That made me quite uncomfortable, and I know that there were other staff (and several nurses) who refused to work with that physician. However, as squirmy as I felt, I thought it was important for me to see first hand what the procedure entailed… because otherwise I’d have to rely on anecdotes and second-hand opinions to draw my own conclusions. I wanted to see this for myself.
I’ll never forget the day I witnessed the first late-ish term abortion. I was preparing my intubation equipment – fidgeting with the Mac size 4 blade, making sure the light worked, when the physician brought the patient into the room on a gurney. The woman’s abdomen was very pregnant, and the Ob/Gyn was stroking her hair and whispering reassuring things to her. The anesthesiologist made small talk with the patient, explaining the nuts and bolts of the anesthesia – the oxygen mask – the propofol – the intubation. I stayed out of the patient’s line of sight and allowed the Ob/Gyn and her resident to spend some final moments with her. The scene was both tense, and yet supportive of the patient.
I initiated rapid sequence intubation with the assistance of the anesthesiologist, and then moved to get the ultrasound machine to visualize the uterus and its contents. Much to my discomfort the fetus was fairly large – and was moving around normally, even sucking its thumb at one point. I asked the Ob/Gyn resident why the fetus was being aborted since it didn’t appear to have any structural abnormalities. She responded that the mother simply didn’t want to have the baby, and had wrestled with the idea of abortion for a long time before she made her final decision.
The rest of the procedure is a bit of a blur – with details too graphic to describe here. But suffice it to say that the resident performing the dilatation and curettage had a fairly difficult time removing the fetus through the cervix, and had to resort to eliminating it in smaller parts, rather than a whole. It was very sad and it took a long time to make sure that the uterus was fully evacuated. I decided that I couldn’t watch another one of these procedures.
The rest of my female abdominal ultrasound experience was obtained at a Planned Parenthood center where very early abortions were performed. Generally, this consisted of suctioning out a tiny yolk sac (and “products of conception”) – without much of a recognizable fetus in the midst. Although these procedures were certainly emotional, they were somewhat less troubling than the later term dilatation and curettage.
What I didn’t expect, however, was that of the approximately 100 abortions I witnessed – none (to my knowledge) of the women requesting them were rape victims, nor was there a life-threatening birth defect in the fetus. Usually the reason they gave was psychological, emotional, or financial – “I just can’t afford to raise a child” or “This is not a good time for me to be pregnant” or “I don’t want this baby” or “I don’t want another baby” or “This was an accident, and I don’t want it to ruin my life.”
I did my very best to adopt an attitude much like the one that the author of the Washington Post article did – “It’s not for me to judge the validity of someone else’s reasons for wanting an abortion… They’re going to do it anyway so physicians need to make sure they’re safe… Women have the right to choose…”
But the reality was that those attitudes didn’t prepare me for the emotional turmoil inherent in the process of abortion. It’s sadder than I thought, more difficult than I thought… and the impact is farther reaching than I imagined. Studies estimate that about 1/3 of US women have an abortion at some point in their lives – that’s a heavy emotional burden that many women carry in silence.
In my opinion women should have the right to choose to have an abortion, but I’d hope that they also consider their right to choose to give their baby up for adoption as well. Some believe that an abortion is “easier” than giving up a baby for adoption – but I’m not so sure that’s the case from an emotional perspective. As far as rape victims or women who are carrying a moribund fetus – the decision to abort may well be emotionally less damaging. But for the majority of women who have abortions for less clear reasons (reasons like the ones I witnessed), I’d really encourage them to consider adoption as an option. Obviously, these decisions are intensely personal and have to be made on a case-by-case basis – and women should be supported either way.
As scientific and rational as I wanted to be about the procedure, I am still troubled by what I experienced as a witness to various abortions. Though I might have “entered the abortion conversation” as the third-year medical student did – after witnessing quite a few, I have a deeper appreciation for the emotional complexity of abortion, and a desire to help women avoid them if at all possible. I wonder if the author of the Washington Post article will change her perspective after she’s witnessed a few of the procedures?
June 8th, 2009 by Shadowfax in Better Health Network, Opinion
Tags: Credentials, Disciplinary Action, Errors, Ethics, Incompetent, Morally Unfit, National Practitioner Data Bank, NPDB, Physician, Reporting
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Bob Wachter, who I generally like and admire, takes on the topic of hospital peer review, stimulated by a
report issued by Public Citizen’s Health, that hospitals rarely report physicians to the National Practitioner Data Bank:
Wachter’s World : Is Hospital Peer Review a Sham? Well, Mostly Yes
Although the public cannot access NPDB reports on individual physicians, healthcare organizations (mostly hospitals) ping the database about 4 million times per year. When it was inaugurated, the best estimates (including those of the AMA) were that the NPDB would receive 5,000-10,000 physician reports each year.
Not so much. Since its launch two decades ago, NPDB reports have averaged 650/year, and nearly half of US hospitals (2845 of 5823) have never reported a single physician! The most extreme case is that of South Dakota, where three-quarters of the hospitals have never reported a single case to the NPDB. I’m sure South Dakota has some wonderful doctors, but the idea that the state’s 56 hospitals have not had a single physician who needed to be suspended for incompetence, substance abuse, sexual harassment, or disruptive behavior since the Reagan presidency is a bit of a stretch, don’t you think?
And on the merits of the matter, it’s hard to dispute that the NPDB has been an abject failure as far as its original goal went: it is not an effective data bank collecting data on suspect and problematic physicians. I think that Public Citizen and Dr Wachter transpose cause and effect, though, when they attribute the blame to the peer review process. The fault, I think lies in the NPBD itself.
The goal may have been laudable and simple — get in trouble, get a file, and keep bad doctors from hurting patients. Wow. Who could oppose something like that? But that’s not how it worked out in the real world. Perhaps it’s a consequence of the fact that it is so infrequently used, but the reality is that being in the NPDB is incredibly stigmatizing, which is not a matter limited to the ego of the reported physician, but also is an essential death sentence to his or her career. This is not a “Oh dear, now I’ll never be Chief of Staff,” sort of career disruption — being in the data bank makes a physician essentially unemployable.
And that’s why it’s shunned: it often seems unjust. There’s no proportionality, no way to indicate the gravity of the transgression, because the full details behind a report are screened from view. Molesting a patient and telling dirty jokes in the OR both show up as “sexual impropriety.” An isolated mistake or an episode of poor judgment is impossible to distinguish from incompetence, as both are filed as “quality of care deficiencies.” When the only punishment is the ultimate one, it’s no suprise that medical staffs are loathe to invoke it.
And it’s expensive. Since a physician at risk of a medical staff action usually knows how high the stakes are, they will commonly lawyer up and fight tooth and nail to prevent any blot on their record. The legal bills for these cases can run into the hundreds of thousands of dollars, and even if the hospital “wins,” all they’ve done is spend a ton of money to get rid of a problem. If they can get rid of him or her for free with a negotiated sham resolution, why would they go through all the expense to persecute the poor bastard as well?
Much of the same can be said for the state licensing boards, to which medical staff committees are also responsible for reporting of suspensions and revocations of privileges.
So, I think it should be noted that this is not a simple “docs are too softhearted to police themselves” issue. It’s that the legal and regulatory tools we have been given are too blunt and indiscriminate for those of us wielding them to feel that they are useful and fair in the vast majority of cases.
Because the true case of the dangerous/incompetent/morally unfit physician is relatively uncommon. Dr Wachter falls right into the false “Good doc/bad doc” dichotomy and buys into the assumption that there is a large cohort of “Bad Doctors” out there that we need to drum out of the profession. There are some, I am sure, but I’ve rarely seen one at our hospitals, and they’re actually quite easy to deal with when you come across them. It’s the gray cases, which comprise the majority of the head-scratchers that we have to deal with in the hospital. It’s the surgeon whose patients love him but just seem to have a lot of complications. It’s the doc who manages to pick a fight with every other member of the medical staff but never quite crosses any bright lines. It’s the creepy male doc who makes all the nurses uncomfortable but never really touches where he shouldn’t. The “incompetent” doc who you wouldn’t let care for your family member but seems to muddle by just well enough to keep from killing anyone.
You all know the one I’m talking about, right? But it can be tough to identify an incompetent doc. I’ve never yet met one whose ID badge or diploma listed them as “incompetent.” In many cases, there’s a legitimate defense to the care provided, even if it’s a weak defense. In many cases an error or errors may have been genuine and severe, but not characteristic of the doc’s general level of quality. The cut and dried “you suck” level of incompetence is rare and far overshadowed by the many cases of borderline physician skills.
The “Bad Doc” approach to this matter also makes the error of assuming that a problem doc is irredeemable and must be expelled from the order. I’ve seen docs who rose and fell and rose again over the long arcs of a career. Some of them needed to go through a formal, sanctioned process involving chemical dependency treatment, most often. Others, however, simply needed attention and managerial support: focused redirection, re-education, sensitivity training or the like, and with appropriate supervision they are able to continue practice. Reporting them to the NPDB is not a solution, at least not a defensible one in the “typical” borderline case. Sometimes you can counsel them or devise a practice plan that works to keep patients safe and the hospital harmonious. But the adversarial relationship makes this hard enough, and the need to carefully work around this death threat of the NPDB is a burden and an impediment to working collaboratively with the “challenged” physicians.
None of this is intended to be a defense for the truly impaired, incompetent, or sociopathic docs out there, or the medical staffs who have enabled them. I’m sure that the problem exists to some degree. But the idea that the NPDB is a valuable or even a positive tool in the vast majority of cases is itself laughable. It was a great idea but as implemented it has been an abject failure. The high-handed folks over at Public Citizen will never admit to it, will never modify it in ways that might make it more functional. They will, rather, rail against the scofflaw docs and hospitals who do not deign to use this blunt and ineffective instrument which has been thrust upon us. And we, working away on Medical Exec and Credentials Committees will be left with ad hoc and jury-rigged approaches to the borderline physicians who represent the more common and more challenging dilemmas in the industry.
*This blog post was originally published at Movin' Meat*
June 5th, 2009 by Dr. Val Jones in Opinion
Tags: Barriers To Adoption, EHR, Electronic Medical Records, EMR, Microsoft Surface, PHR
11 Comments »
Have you ever been ignored by someone who was texting or otherwise engaged in a digital conversation? Did you feel that the person was being rude and unresponsive to you? If your answer to both of these questions is “yes” then you will understand the real reason why some doctors don’t want to adopt electronic medical records systems (EMRs).
As sappy as this may sound, most physicians were drawn to medicine because they wanted to help people, save lives, and improve the quality of life for those suffering from disease. Even after we’ve been beaten up by our training programs, and weighed down by debt and the mountains of paperwork required by a broken healthcare system, most of us still retain that do-gooder kernal inside us – we genuinely care about our patients.
And so because we care, we know instinctively that the human side of medicine – the attentive listening, the visual cues, the continued eye contact, and the careful history and physical exam – is critical to our profession. The problem we have with EMRs is that they often interrupt the sensitive and intuitive parts of what we do. EMRs and other digital “tools” designed to make our work more efficient, may do so at the expense of the human connectedness our patients deserve and need.
Most EMRs, as they exist today, are not designed to bring patients into the conversation. In order to maximize efficiency, the physician must type while the patient is talking – usually turning their gaze and even their whole bodies away from the individual or family. Those of us who feel that this behavior is socially inappropriate will take a verbal history from the patient and then type it up from memory later – this creates more work than if we’d simply taken notes during the conversation in a paper-record, and may introduce recollection bias if we do our typing at the end of a long day of seeing many patients.
There is certainly a generation gap in terms of EMR adoption (as my friend Dr. Geeta Nayyar has noted) – our new crop of doctors are very comfortable with EMRs and wireless tools of various kinds, while the “older” doctors are often highly resistant to adopting a digital system. But before we label senior physicians as “obstructing progress” – let’s look beyond the technology issues (yes, it takes time to learn how to do something a different way) and at some of the emotional reasons why physicians don’t like what EMRs do to their patient relationships.
Time and again I’ve heard my peers (who use EMRs in hospitals) say that they feel that they spend most of their time “talking to the computer” rather than the patient. They are wracked with guilt about this, and have actually lost a portion of their “job satisfaction” as a result. They know that the digitization of healthcare has robbed them of the luxury of full history and physical exams, conducted in an uninterrupted face-to-face encounter with their full attention on the patient. They feel like a robot – like a mere collection of algorithms used to process people in an “evidence based” framework. And the patients – they report that their doctors are hurried, uncaring, and potentially replaceable with a robot.
In my opinion, EMR manufacturers must understand the collateral damage that their products can do to the physician-patient relationship and create EMRs that engage patients in the physician encounter. I have seen at least one prototype product that is trying to do this (and there may be many more – it’s difficult to keep up with all the new innovations, so please leave a comment about other products that you know of), Microsoft’s Surface. Surface allows the physician and patient to sit together at a table with a screen embedded in its top. The physician can bring up lab results, radiology images, and medical records to discuss them with the patient so they can see it at the same time. I really like this concept, since it facilitates electronic record keeping while engaging the patient in the encounter.
When EMR vendors and civil servants bemoan the slow technology adoption rates of physicians, I urge them to recognize that there is more at play than just “resistance to change.” There is a resistance to dehumanizing doctor-patient interactions, to turning one’s back on a crying patient to type notes on a laptop, to spending more time “talking to a computer” than talking to a patient. That resistance is actually a good thing – it means we still care, we have hearts, we are human.
Now, to get physicians to adopt EMRs – don’t use a stick (“adopt our EMR or we’ll fine your practices”) use the younger generation of physicians (already comfortable with technology) to teach the older ones how to integrate digital record keeping into their workflow. During that interaction, I believe the senior physicians will be able to teach the junior ones a lot about the art of humanizing their patient interactions, while the younger ones train them about the technical process of incorporating EMRs into their own workflow.
In summary, EMR adoption is slow not just because of cost and technical skills barriers, but because of the potential dehumanizing effect they can have on medical practices. Senior physicians may understand this risk better than junior ones, and should be admired for their desire to maintain fewer barriers in their relationship with patients. EMRs created with the ability to include patients in the conversation can reduce the potential social damage they often introduce in patient encounters. Peer-to-peer training is valuable in improving adoption rates, teaching junior physicians the social etiquette important in a caring doctor-patient relationship (and to maintain the art of listening and observing), and helping senior physicians learn how to use technology to achieve the tasks they currently complete by other methods.
May 30th, 2009 by DrRich in Better Health Network, Opinion
Tags: ACS, American College of Surgeons, Cost Savings, Elective Procedures, Finance, healthcare, Medical Tourism
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Earlier this year, DrRich offered several potential strategies for doctors and patients to consider, should healthcare reformers ultimately decree it illegal for Americans to seek medical care outside the new universal system. This eventuality (i.e., making it a crime to spend your own money on your own healthcare) may not be as far fetched as one might think at first glance, since in societies where social justice is the ultimate goal, such individual prerogatives must be criminalized.
At that time, DrRich offered several creative solutions to this problem, including offshore, state-of-the-art medical centers on old aircraft carriers, and combination Casino/Hospitals on the sovereign soil of Native American reservations. A reader subsequently offered the possibility of simply establishing institutions something like the “Cleveland Clinic Tijuana,” i.e., cutting-edge medical centers just south of the border. (This solution would have the added advantage of encouraging the government to finally close the borders once and for all, employing whatever means it might take, including military patrols, minefields, and missle-armed drone aircraft.)
As entertaining as it might be to imagine such solutions, a readily available, though much more mundane, solution exists today – medical tourism.
Medical tourism, where one travels outside one’s country in order to obtain medical care elsewhere, is a booming business. A number of superb state-of-the-art medical centers expressly aimed at attracting medical tourists have been established in the Middle East, Singapore, India, China and elsewhere in Asia. These institutions cater to citizens of the world whose own healthcare systems cannot (or will not) provide in a timely fashion (or at all) the level of care patients may desire. They offer modern hospitals, numerous amenities, luxurious accommodations, attentive nursing care, top-notch doctors – and they do it all for a tiny fraction of what the same care might cost (if you can even find it) in the U.S. and other “first world” nations.
Obviously medical tourism is not particularly feasible for medical emergencies such as heart attack or stroke, or for chronic illnesses such as diabetes, congestive heart failure, or Parkinson’s disease, which require frequent visits and long-term management. What is feasible is to become a medical tourist for those one-time medical services that can be scheduled and planned, for which there is a long waiting period at home, or which is simply too expensive in one’s own country. Such medical services often include coronary artery bypass surgery, hip replacements, knee replacements, and numerous minimally-invasive and not-so-minimally-invasive surgical procedures. In other words, medical tourism to a large extent is something one does for elective (i.e., non-emergency) surgery.
It ought not be a surprise, therefore, that the first organization of American physicians to issue a formal policy statement regarding medical tourism is the American College of Surgeons.
The reaction of American surgeons to medical tourism ought to be obvious. They hate it. Elective surgical procedures – the very procedures for which Americans become tourists – are the bread and butter of most surgical specialties. And here go their prospective patients, off to Singapore for their lucrative bypass surgeries. American cardiac surgeons, for instance (already underemployed, thanks to American cardiologists throwing stents at every tiny coronary artery indentation they they can justify as a “blockage”), are nearly apoplectic at the idea.
It’s always fun to read formal policy statements which attempt to deliver an entirely self-serving message whose essence is, “We hate this and if you do it we’ll hate you,” but in which it is necessary to deliver the message in a polite, politically correct, non-judgmental, helpful and even friendly manner.
The surgeons in general have made a good effort, as you can see if you’d like to read the policy statement for yourself. It’s pretty much what you would expect – “Go ahead and have your knee replaced in Timbuktu if you want to. It’s your right, so go ahead and devil take the hindmost. Just don’t come crying to me when things go south a month later.” Only, of course, the surgeons employ the obligatory very polite and professional tone.
DrRich is struck by two aspects of the surgeon’s policy statement on medical tourism.
First, the surgeons begin with a litany of dire warnings regarding all the medical considerations one must take into account before trusting one’s health to foreign medical hands:
“Some of the intangible risks include variability in the training of medical and allied health professionals; differences in the standards to which medical institutions are held; potential difficulties associated with treatment far from family and friends; differences in transparency surrounding patient discussions; the approach to interpretation of test results; the accuracy and completeness of medical records; the lack of support networks, should longer-term care be needed; the lack of opportunity for follow-up care by treating physicians and surgeons; and the exposure to endemic diseases prevalent in certain countries. Language and cultural barriers may impair communication with physicians and other caregivers.”
These are all very important considerations. DrRich notes, however, that these very same considerations (even the warning about endemic diseases, once one allows for the MRSA infections which are secretly “endemic” in some American hospitals) must also be taken into account before agreeing to receive care even in an American institution. It may be that these considerations are more an issue in top-notch foreign hospitals than in your average American hospital, but DrRich is not convinced this is the case, and the surgeons do not provide any evidence that it is. That is, DrRich sees this very good advice as being equally applicable whether one is considering becoming a medical tourist, or just a typical American patient.
Second, and most astoundingly, DrRich notes – not so much with interest, but more with awe – that the surgeons are beseeching their patients to consider just how difficult it might be to launch a malpractice suit against foreign doctors. (DrRich himself does not know how difficult this would be. Given that we are being so strongly urged these days to merge the American legal system with international law, it might not be much of a problem for long.) Indeed, the potential difficulty in suing foreign doctors appears to be the chief differentiator, and the primary argument in favor of good-old-American-surgery. The surgeons, in essence, are saying, “Let us do your surgery, because we’re easier to sue if we screw up.”
This, from the very body of American physicians who are most at risk for malpractice suits, and who traditionally have been most vociferous in favor of malpractice reform.
DrRich can only shake his head in wonderment. If medical tourism is viewed by surgeons as such a dire threat that they are formally embracing medical malpractice suits as their chief weapon against it, then medical tourism must have already caught on far more than most of us realize.
Which means, of course, that when healthcare reform takes place, medical tourism will likely enter a phase of truly explosive growth.
And so, Dear Reader, thanks to this critical clue provided by our friends in the American College of Surgeons, DrRich can confidently offer yet another nugget of investment advice. He formally recommends the medical tourism industry – now in its infancy – as an area ripe for growth.
*This blog post was originally published at The Covert Rationing Blog*
Do you remember this person? She is a bedside nurse. She walks up and down hospital hallways in her white nursing shoes all day long while caring for her patients. She is trained for active duty. I’m asking you this question because nursing researchers have had an epiphany. They believe that they have discovered something new in the field of bedside nursing.
