July 9th, 2007 by Dr. Val Jones in Opinion
Tags: Hospitals, Medical Training, Quality
5 Comments »
One of my colleagues just forwarded me a NY Times article by Jerome Groopman. The article begins with the issue of inexperienced interns – how newly minted MDs begin clinical care for patients in July of each year, and how these rookies can make harmful mistakes.
He goes on to explain that doctors aren’t trained to think well about the diagnostic process (the thesis of his recent book) and that we’d all benefit from studying cognitive psychology.
Dr. Groopman makes some interesting points in this article, but I was most struck by his flippancy regarding the dangers of getting treatment in July. He simply says, “Today, most hospitals closely watch over interns.”
I personally think the issue is more sinister than that – there are many ways that an intern can make mistakes, without ordering a single test or procedure, and under the full scrutiny of red tape regulations and documentation practices.
When an intern fails to recognize a life threatening condition and chooses to do nothing, or to let the patient wait for an extended period of time before alerting his or her team to the issue, serious harm can befall that patient. And that harm is not caused by inexperienced procedural technique, or ordering the wrong medicine – it’s caused by doing nothing. This “doing nothing” is the most insidious of intern errors – and it is not remedied by any form of hospital quality improvement initiatives. It is the risk that a hospital takes by having inexperienced physicians in the position of first responders. Interns gather large amounts of information about patients and then create a summary report for their supervisors. The supervisors (more senior residents) don’t have time to fact check every single case, and must rely on the intern’s priority hierarchy for delivering care.
But many hours pass between the time an intern examines a patient and when a supervising physician checks back in with that patient. And within that period of time, many conditions can deteriorate substantially, resulting in the loss of precious intervention time.
Dr. Groopman describes an experience from his own life in which a surgical intern (in July) correctly diagnosed his son with an intussusception (twisted bowel) but then incorrectly determined that the baby could wait to go to the O.R. Of course, untreated intussusceptions are nearly always fatal, and each minute that passes without intervention can increase the risk of death.
And so, in my opinion, it is in fact more dangerous to be admitted to a teaching hospital in July, but not necessarily for the reasons that people assume (procedures performed by inexperienced physicians or drug errors – though those mistakes can be made as well). Rather, it is because interns don’t have the clinical experience to know how to prioritize their to-do lists or when to notify a superior about a patient’s health issue. Timing is critically important in quality care delivery – and that variable is not controlled by our current intern oversight system.
Now that I’ve completely terrified you – I will offer you a word of advice: designate a patient advocate for your loved one (or yourself) if you have to be in the hospital as an inpatient (especially in July). If you can, find someone who is knowledgeable about medicine – and who knows how to navigate the hospital system. A nurse, social worker, or physician are great choices. That person will help you ensure that concerns are prioritized appropriately when your intern doesn’t yet fully appreciate the dangers behind certain signs symptoms. If you have no advocate, then befriend staff members who are particularly caring and experienced. Be very nice to them – but don’t be afraid to insist on being examined by the intern’s supervisor if you really are concerned. Unfair as it may seem, sometimes the most vocal patients get the best care.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 1st, 2007 by Dr. Val Jones in Health Policy, Opinion
Tags: Hospitals, Medicare, News
6 Comments »
There were a series of amusing anecdotes presented at the
very beginning of Sicko. Various people
were denied coverage by health plans for things that didn’t have the right
coding or were submitted incorrectly.
One woman received a message that her ambulance transportation to the
hospital from the scene of a car accident (where she was knocked unconscious)
was not covered by her health insurance because she did not obtain pre-approval
for the ambulance ride. She asks, “When
could I have called for pre-approval?
It’s hard to get permission when you’re unconscious.”
Another person was declined coverage because he was too thin
(he was six feet tall and only 130 pounds), and one young woman was
denied because she was overweight (5’1” and 175 pounds).
While these denials are laughable, they are ridiculous
specifically because they are decisions that appear to be made by a computer –
or perhaps by applying inflexible rules to real life scenarios without the
benefit of human interpretation. [See my cartoon on the subject.]
And as we consider Mr. Moore’s proposed solution to the apparent
capriciousness of health insurance company coverage policies – we see that his
single-payer solution is really no different.
He is trading one impersonal decision maker for another. Big government is no more capable of
delivering personally relevant care than is the health insurance industry. The problem with both is that they take
decision-making away from the patient and those closest to their situation – the providers who have a
much better sense of what is needed and appropriate.
As a physician it really upsets me when a third party payer denies coverage of an important treatment to my patient. I understand that we have to have some broad, population-based rules for medical coverage as a means for cost containment – but a one-size-fits-all system will always fail some people. We physicians are regularly on the phone on their behalf, explaining to appeals associates why our patient needs X, Y, or Z… and then have to re-explain the medical necessity up the chain of command until a Medical Director is finally reached, who then has no incentive (other than basic human decency) to give in to the pleading physician’s request on behalf of her patient. We (and our staff) spend uncompensated hours upon hours doing this every week.
And Medicare creates rules to deny coverage to people too (and it probably doesn’t save on administrative costs over health insurance plans anyway, notes Charlie Baker at Harvard Pilgrim Healthcare, Inc.). So from a physician’s perspective it feels as if we’ve had our clinical judgment usurped by bureaucracy and for-profit health insurance companies. We have been reduced to claims advocates rather than clinicians. It is exhausting and infuriating – and I don’t see this improving any time soon (and neither does Paul Levy at Harvard).
Healthcare is not free, as Dr. Leap points out, and unfortunately it’s also not personal. And that’s what I am lamenting – the depersonalization of medical care. My patients will not be able to make a full range of informed choices with my help – they will be given a very limited menu of options from their third party payer – who will argue that they are not limiting care because the patient can always pay out-of-pocket for anything their physician believes is necessary, but is not covered under their plan. And so where does that leave the patient on a modest income? Effectively, they are indeed limited to the options covered by their third-party payer. And this is so ironic, given the new push for personalized medicine (optimizing individual treatment via genetic testing, etc.) In the end it seems that we’re aiming for personalized medicine and an impersonal healthcare system. And maybe that’s part of what’s “sicko” about all of this.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 21st, 2007 by Dr. Val Jones in News, Opinion
Tags: Complementary And Alternative Medicine, Pain Management
2 Comments »
An interesting meta-analysis was recently published in the Annals of Internal Medicine. It showed that acupuncture for knee arthritis can reduce pain, but its effects are likely due to the placebo effect. The placebo effect is nicely described in Wikipedia:
A so-called placebo effect occurs when a patient’s symptoms are altered
in some way (i.e., alleviated or exacerbated) by an otherwise inert
treatment, due to the individual expecting or believing
that it will work. Some people consider this to be a remarkable aspect
of human physiology; others consider it to be an illusion arising from
the way medical experiments are conducted.
Because of the mind-body connection, we humans can actually alter our experience of pain if we will ourselves to do so. We experience more intense pain when we’re depressed or particularly fixated upon it (via boredom for example). And we experience less pain when we’re happy (take women immediately after giving birth – they barely even notice the Ob as she sews up their tears).
When it comes to pain management, there are many non-medical techniques that can improve the experience of pain, even if it doesn’t affect the physiology of it. And so if we can find ways to put ourselves in a frame of mind that minimizes the pain sensations, that can be really valuable.
But as far as the physiology of acupuncture is concerned, we have not yet been able to explain exactly how it works. I’ve often wondered if it may be due to the fact that the sharp pain fibers (stimulated by acupuncture needles in different locations) travel along slightly different nerve pathways than the fibers from the actual painful area for which one is getting the acupuncture. The pain input might subconsciously distract the mind from the duller (or more chronic) pain input from the arthritic joint (or other pain generator). This might explain why sham acupuncture works (meaning, putting the needles anywhere, rather than in certain specified meridians).
I’m sure some of you will disagree with this – and it’s only a theory. But it does seem that inserting tiny sharp needles into the skin improves pain sensations in knee arthritis – no matter where the needles are put. How do we explain this placebo effect? I’m not sure – but if the treatment is quite harmless, and seems to decrease pain, how important is it to have an explanation?
And by the way, I was just about to post this when I found another interesting article about acupuncture in the journal Circulation. In this study, they found that acupuncture (when performed 3-5 times a week for 30 minutes each time) was able to reduce blood pressure by about the same amount as a low dose ACE inhibitor pill. Interestingly, though, in this case the needles placed according to Traditional Chinese Medicine (in certain meridians) rather than sham acupuncture (random placement) decreased blood pressure significantly more. I wonder if the TCM placements are activating the autonomic nervous pathways in this case?
At this point the jury’s still out on how all this works. But acupuncture does have measurable effects – even if they’re due to the placebo effect and/or stimulation of the autonomic nervous system. The real question is: would you rather pop a pill each day or travel to and from an acupuncturist’s office 3-5 times a week for 30 minute treatment sessions?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 20th, 2007 by Dr. Val Jones in Opinion
Tags: Family Medicine, Parenting, Pediatrics, Urology
3 Comments »
Little did I know that there is a raging debate about whether or not it’s a good idea to circumcise male babies. I was reading #1 Dinosaur’s blog and almost fell off my chair at the passionate series of comments. Apparently, 90% of American males were circumcised in the 1960s, but that rate has dropped to about 57% today.
Pro Circumcision: circumcision decreases the rate of transmission of HIV and HPV and is hygienically desirable. It does not appear to adversely affect sexual function, is a fairly minor and non-traumatic procedure, and is a reasonable health intervention.
Against Circumcision: condoms are more effective at reducing HIV and HPV transmission than circumcision. It is ethically wrong to circumcise an infant because he cannot give his consent and the procedure is painful. Some people believe that there is an important sensory nerve in the frenulum that is often severed during circumcision.
The American Academy of Pediatrics takes the position that: Existing scientific evidence demonstrates potential medical benefits of
newborn male circumcision; however, these data are not sufficient to
recommend routine neonatal circumcision.
The American College of Obstetricians & Gynecologists takes no position: Newborn circumcision is an elective procedure to be performed at the
request of the parents on baby boys who are physiologically and
clinical stable.
I had always assumed that circumcision was a personal choice that people didn’t feel that strongly about one way or the other. I guess I was wrong!
Why do you think this topic is so passionately debated?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 4th, 2007 by Dr. Val Jones in Opinion
Tags: Nurses, Pediatrics
No Comments »
In a bleary eyed state I misread a blog post by PandaBearMD. He was on one of his well- written, sarcastic tears, and (jokingly) blamed nursing salaries for the rise in healthcare costs. I didn’t get the humor of that, and proceeded to defend my nursing colleagues. Of course, I took some hits for being unable to recognize sarcasm, but this event got me thinking about nurses…
I have always been grateful for the wonderful work that nurses do – and as I think back at all the amazing feats they’ve accomplished in front of my very own eyes, I thought I’d start a list:
NICU: can place an I.V. in a 1 lb preterm baby with veins the diameter of hair (but docs: don’t TOUCH the baby!)
ER: can put an I.V. in a 400 pound, anasarcic patient with no palpable pulses.
Psychiatric ED: can convince a fulminantly psychotic, violent patient to sit quietly and play with a teddy bear while waiting for the doctor to see him
Medical Floors: can clean up a fecal mess so foul that even the anosmic wouldn’t have the courage to enter the room – and do it in such a way that the patient feels no personal embarrassment
OR Nurse: will anticipate the instruments needed for an unforseen surgical complication and have them ready for use before the doctor gets a chance to ask for them
Pediatric ED: can distract a small child with stuffed animals, toys, and picture books so successfully that they don’t notice sutures being placed in their hand.
Obstetrical Nurse: can withstand the force of a 200 pound leg pressing against her for hours on end as mom bears down to push the baby out of the birth canal
Rehab Nurse: can get any patient out of bed, single handedly, and with little obvious effort (while the rest of us call for the Hoyer Lift, and 3 resident physicians)
This is just the beginning of a long list of magical things that nurses can do… please share some of your favorites!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
