A well-to-do patient recently boasted to me about an expensive insurance plan that he had purchased to “guarantee” that he had access to the best healthcare in the United States. Coverage included access to elite academic centers (all the usual suspects) and a private jet service for emergencies. He was utterly confident that his investment was worth the price, but I withheld my own misgivings.
Hospital quality data suggest that “fancy, brand name hospitals” provide better patient care. But unfortunately there is no guarantee of good outcomes for anyone who sets foot in a hospital. My experience doesn’t exactly square with quality data, and although I realize that there are teams of public and private sector analysts out there furiously rating and ranking hospitals with all manner of outcomes data, I don’t think it means a whole lot for the individual “worried well” patient. Here’s why:
1. Higher overall patient complexity may mean less attention for you. Academic medical centers specialize in caring for those who are often too sick or too complicated to be cared for elsewhere. This means that each patient requires more staff time to address their long list of diseases and conditions. Everything from medication reconciliation to medical testing, to bedside care, requires more time from each provider taking care of them. If you happen to be on a medical floor with complicated neighbors, expect to see less of your doctors and nurses. It’s not fair, but this happens regularly at elite centers, and it’s not in your best interest.
2. Less-experienced physicians may be providing the bulk of your care. Academic teaching hospitals are actively involved in training young doctors, and the least experienced among them will likely be providing the majority of your care (and reporting up to the overseeing physicians). Because of the exhausting complexity of very sick patients, if you are not among the very sickest (or provide a steady stream of diagnostic conundrums requiring the input and expertise from the top experts), your care will be left in the hands of the residents. This doesn’t mean you won’t get good care, but it introduces some degree of risk.
3. You may be exposed to really bad germs. Drug-resistant bacteria are born in places that use big-gun antibiotics. Again, with more challenging cases and infectious diseases in the patient mix, more antibiotics are used and more drug-resistant bacteria develop. Although academic centers make great efforts not to spread infections, it can happen. And if you do get a hospital-acquired infection, it’s probably going to be a bad one.
4. More providers means more opportunity to make EMR-based medical errors. As I’ve argued in recent blog posts, electronic medical records are error prone for a number of reasons. The more people entering data into your record, the more opportunity for mix ups and confusions. Academic medical centers may boast more specialists and a higher staff to patient ratio, but this is not always a good thing. The fewer the number of providers caring for you (especially nurses), the better you are known to them, and therefore the lower the risk of certain mistakes.
5. More tests and procedures aren’t always a good thing. Academic centers have access to a larger breadth of technology, which means that they are more likely to order more tests and procedures. Imaging studies, biopsies, lab tests, and advanced surgical procedures can provide additional information that can change the course of therapy. But they also have the ability to initiate wild goose chases, further testing, unnecessary anxiety, and additional risk (and expense) to the patient. Judicious use of technology is important, but with less experienced physicians on the team, they are more likely to reflexively order a test than to rely on their clinical experience regarding diagnosis and treatment.
6. Many “moving parts” increase your risk for errors, mix ups, and longer wait times. The larger the hospital, the more chances there are for accidental substitutions, name confusion, and test scheduling conflicts. It may seem improbable that these events still occur (Don’t we have bar codes on wrist bands that have solved this problem? You ask.), but if you’re a physician clicking between electronic medical records of patients with the same last name, no bar code will save you. I myself was a patient in the ER of a large elite academic center once, when the security guards confused me with a volatile psychotic patient previously located in the bay that my stretcher was moved into. They almost got the four-point restraints on before I convinced them to re-check my identity with the nurses. Awkward. Also, if you need an MRI or CT scan at a level 1 trauma center, you could be waiting a long time for it as sicker patients bump you from the schedule.
7. Traveling to a center of excellence means post-acute care services will be harder to arrange. If you are recovering from a serious illness or surgery far away from home, case managers will probably have a harder time connecting with services to help you upon discharge. If you need visiting nurses, home-based therapists, durable medical equipment, or follow up care (either with specialists or primary care physicians) all of that will be more challenging to arrange because the case managers don’t have them in their virtual Rolodex. Because of the complexity of the healthcare system, it takes years of effort for good case managers and discharge planners to streamline the process of getting through to the “right person” at each service provider and providing them with the “correct” insurance information and completed forms and paperwork. If they’re lobbying for you out of state or in a far away county, they will probably end up spending a lot of time on hold, or talking to the wrong person. And when you finally arrive home and the visiting nurse doesn’t show up, or you don’t have your walker after all… you will not be happy.
8. You may be stuck with an enormous, post-hospital price tag. Most people nowadays have insurance that covers care at certain “preferred” facilities at a much lower cost to the patient. If you go “outside of network” you may be responsible for a much higher percentage of your care cost than you bargained for. Before you decide to opt for the big brand name academic medical center for your care or procedure, double check with your insurance provider regarding what your part of the cost will be.
If you (or your loved one) are in the unfortunate position of having a rare, life-threatening, or extremely complicated host of diseases and conditions, then you may have no choice but to go to an academic medical center for care. If you’re like my wealthy patient, though, and can afford what you think are insurance upgrades to provide you with access to the “best care available,” you may discover that better care is actually found closer to home.
In an upcoming post, I’ll describe my experience with hospital characteristics that tend to predict a higher quality of care. You may be surprised to find that there isn’t a whole lot of overlap between my personal measures and what we are led to believe are the important ones.
In case you hadn’t seen this announcement in my Twitter stream – there are a number of writing fellowships available for US medical students and residents. (Bloggers and those heavily engaged in social media are preferred.) Join The American Resident Project Writing Fellows in brainstorming about how to make the healthcare system better for future generations. Fellowships are awarded on a rolling basis. Opportunities for travel are included. From their website:
The American Resident Project is a platform for future physician leaders – medical students, residents and physicians newly in practice – to connect, explore ideas for transforming American health care delivery, and exchange these views with other health care providers and opinion leaders across the country.
Sponsored by ThinkWellPoint, The American Resident Project focuses on key issues affecting today’s frontline physician workforce, including:
New care coordination models
Strategies for patient engagement
Innovations in health technology
Join our growing community, lend your voice and share your ideas on these and other important topics shaping the future of health care delivery in America.
I will be playing a mentorship role in the program going forward, and look forward to meeting some of my young Writing Fellows in the near future!
Apply for the fellowship here.
As I travel the country providing coverage for inpatient rehab units, I have been struck by the generally high quality of nursing care. Excellent nurses are the glue that holds a hospital unit together. They sound the first alarm when a patient’s health is at risk, they double-check orders and keep an eye out for medical errors. Nurses spend more time with patients than any other hospital staff, and they are therefore in the best position to comment on patient progress and any changes in their condition. An observant nurse nips problems in the bud – and this saves lives.
Not only are nurses under-appreciated and under-paid, they are suffering as much as physicians are with new digital documentation requirements. Just as patients are receiving less face time with their physicians, they are also suffering from a reduction in bedside attention from nurses. The need to record data has supplanted our ability to listen to the patient, causing anguish for patients, physicians, and nurses alike.
This being our lot (and with continued “quality improvement” policies that will simply add to the documentation burden) we must find ways to optimize patient care despite inane bureaucratic intrusions. I believe that there are some steps that nurses and doctors can take to improve patient care right now:
1. Minimize “floating.” (Floating is when a nurse is pulled from one part of the hospital to fill in for a gap in coverage in a different unit). It is extremely difficult for nurses to take care of a floor full of patients they’ve never met before. Every time that care of a patient is handed off to someone else (be they MD or RN), there is a risk of forgetting to follow through with a test, procedure, or work up. Simply knowing what “normal” looks like for a given patient can be incredibly important.
For example, left sided weakness is not concerning in a patient with a long-time history of stroke, but what if that is a new finding? If you’ve never met the patient before, you might not realize that the weakness is new and constitutes an emergency. How does a nurse know if a patient’s skin ulcer/rash/pain etc. is better or worse than yesterday? Verbal reports don’t always clarify sufficiently. There are endless advantages to minimizing staff turnover during a patient’s hospital stay. Reducing the total number of nurses who care for individual patients should be a number one priority in hospitals.
2. If you see something, say something. There are a host of reasons why nurses may be hesitant to report patient symptoms. Either they don’t know the patient well and think that the new issue could be “normal” for that patient, or perhaps the physician managing the patient has been unreceptive to previous notifications. However, I am always grateful when a nurse goes out of her way to tell me her concerns, because I generally find that she’s on to something important. My general rule is to over-communicate. If you see something, say something – because that episode of patient anxiety in the middle of the night could be a heart attack. And if I don’t know it’s happening, I can’t fix it.
3. Please don’t diagnose patients without input. I’ve found that nurses generally have excellent instincts about patients, and many times they correctly pinpoint their diagnosis. But other times they can be misled, which can impair their care priorities. For example, I had a patient who was having some difficulty breathing. The nurse told me about it immediately (which was great) but then she proceeded to assume that it was caused by a pulmonary embolism. I explained why I didn’t think this was the case, but she was quite insistent. So much so that when another patient began to have unstable vital signs (and I requested her help with preparing for a rapid response) she stayed with the former patient, believing that his problem was more acute. This doesn’t happen that frequently, but I think it serves as a reminder that physicians and nurses work best as a team when diagnostic conundrums exist.
4. Help me help you. Please do not hesitate to come to me when we need to clean up the EMR orders. If the patient has had blood glucose finger stick checks of about 100 at each of 4 checks every day for 2 weeks, then by golly let’s reduce the checking frequency! If the EMR lists Q4 hour weight checks (because the drop down box landed on “hour” instead of “day” when it was being ordered) I’d be happy to fix it. If a digital order appears out of the ordinary, ask the doctor about it. Maybe it was a mistake? Or maybe there’s a reason for Q4 hour neuro checks that you need to be aware of?
5. Let’s round together. Nurses and physicians should really spend more time talking about patients together. I know that some physicians may be resistant to attending nursing rounds due to time constraints, but I’ve found that there’s no better way to keep a unit humming than to comb through the patient cases carefully one time each day.
This may sound burdensome, but it ends up saving time, heads off problems, and gives nurses a clearer idea of what to look out for. Leaving nurses in the dark about your plan for the patient that day is not helpful – they end up searching through progress notes (for example) to try to guess if the patient is going to radiology or not, and how to schedule their meds around that excursion. Alternately, when it comes time to update your progress note, isn’t it nice to have the latest details on the patient’s condition? Nurses and doctors can save each other a lot of time with a quick, daily debrief.
6. Show me the wounds. Many patients have skin breakdown, rashes, or sores. These are critically important to treat and require careful observation to prevent progression. Doctors want to see wounds at regular intervals, but don’t always take the time to unwrap or turn the patient in order to get a clear view. Alternatively, some MDs simply unwrap/undress wounds at will, leaving the patient’s room without even telling the nurse that they need to be re-wrapped. In some cases, it takes a lot of time to re-dress the complex wound, adding a lot of work to the nurse’s already busy schedule (and offering little benefit, and some degree of discomfort, to the patient).
Nurses, on the other hand, have the opportunity to see wounds more frequently as they provide dressing changes or peri-care at regular intervals. Most nurses and doctors don’t seem to have a good process in place for wound checks. I usually make a deal with nurses that I won’t randomly destroy their dressing changes if they promise to call me to the patient’s bedside when they are in the middle of a scheduled change. This works fairly well, so long as I’m willing/able to drop everything I’m doing for a quick peek.
These are my top suggestions from my most recent travels. I’d be interested in hearing what nurses think about these suggestions, and if they have others for physicians. I’m always eager to improve my patient care, and optimizing my nursing partnerships is a large part of that.
If you (or a loved one) have been admitted to a hospital recently, you were probably surprised by the number of times you were asked the same questions. At first you might assume that the staff are being diligent in double-checking your information, but after the fifth healthcare provider asks you to explain why you’re there, you start to feel as if interacting with “the system” is like talking to a person with no short term memory. It’s as if the hospital itself has some kind of dementia.
Recent adoption of electronic data collection, shift working, team management, and over-specialization have exponentially increased the complexity of patient care. Unfortunately, the complexity is fueling medical errors, repeat and unnecessary testing, as well as misdiagnoses. As primary care physicians have eloquently argued, being cared for by those who don’t know you can be a huge cost driver, and create all manner of unnecessary anxiety. Perhaps a true story will help to illustrate my point?
Not too long ago, I was caring for a patient in an acute rehab unit. Over a three week period of time I got to know her idiosyncrasies quite well. She had had a recent chest surgery and the surgical site was exquisitely tender, but without evidence of infection. In addition, she was allergic to certain kinds of tape and had had an unfortunate blistering reaction to the tape that had been near her surgical site. She had anxiety disorder that was well managed with medicine and talk therapy. She had a large family who visited her daily, some of whom had decided not to vaccinate their children. I had spent a good deal of time helping them to understand the risks associated with those choices.
I signed out my patient’s care to the weekend hospitalist team on Friday afternoon, and was alarmed to discover my patient in an isolation room on Monday morning, in the midst of a nervous breakdown, and surrounded by gowned family members who were furiously calling for emergency transport of distant children to various hospitals. I had not heard a peep from the hospitalists about events over the weekend, and immediately gowned up to find out what was going on.
My patient sobbed, “The doctor told me I have shingles. Now my grand children are going to get chicken pox and they’ll have brain damage!”
“Which doctor told you that you have shingles?” I asked.
“I don’t know his name. Some doctor who was here this weekend,” she wailed.
“How did he know you had shingles?” I said, sitting down next to her bed, trying to console her.
“He looked at my chest rash.” She replied, pointing to the patch of contact dermatitis at the site of the recent surgical tape removal. “He asked me if it was painful and I said ‘yes.’”
“But it’s the surgery site that’s painful as it has always been, right?” I said.
“Yes, it’s the same pain.”
It dawned on me that a linear patch of painful blisters did look a lot like shingles, especially to someone who had never seen the patient before. I could see why the hospitalist suspected it, but unfortunately he wasn’t aware of her long standing wound tenderness or tape reaction. The fallout from this well-meaning misdiagnosis was especially large, given the psycho-social context. A large, anxious family, with many unvaccinated kids who had traveled from far away to see grandma in the rehab unit over the weekend. It was the perfect storm.
Needless to say, it took me several days to unravel the damage, reassure the family, and recall the “emergency chicken pox” ER visits that were planned in distant parts of the state (where the kids made their home). The pregnant nurse who was treating the patient over the weekend had to create a full report to employee health about her “high risk encounter.” And in the end, the family and nursing staff didn’t feel completely certain that she didn’t have shingles, since it was officially documented in the EMR by at least one physician, no matter what my argument.
This is just one example of how cross-sectional relationships with patients (rather than the preferred, longitudinal kind), can wreak havoc. Because of the incredible degree of turnover inherent in today’s inpatient care systems, patients are examined “from scratch” by every new shift of nurse, physician, physical therapist, case manager, etc. There is very little context available to assist with interpreting how the patient is doing compared to their previous state. Searching for such pearls can be time consuming in a medical chart that is not designed for clear communication, but billing purposes.
What are we to do when faced with a new patient with a concerning complaint? Search the chart for historical clues, look for a staff member who has known them longer than one shift, or perhaps ask the patient:
“So can you tell me again why you came to the hospital?”
In my last post I wrote about the communication difficulties caused by electronic medical records systems. The response on Twitter ranged from sentiments including everything from “right on, sister” to “greedy doctors are only complaining about EMRs because of their price tag.” The disconnect between policy wonk’s (and EMR vendor’s) belief in the transformative power of EMRs and exasperated clinician users of these products is jaw-dropping. Physicians are often labeled as obstinate dinosaurs, blocking progress, while policy wonks are considered by physicians to be living in an alternate reality where a mobile phone app could fix all that is wrong with the healthcare system.
Being on the dinosaur side, I thought I’d try a quick experiment/analogy to demonstrate that EMR dissatisfaction is not a mere cost artifact. To show what happens when a digital intermediary runs medical information through a translator, I selected a random paragraph about the epidemiology of aphasias from an article in Medscape. I copied and pasted it into Google translator and then ran it backwards and forwards a few times in different languages. In the end, the original paragraph (exhibit A) became the second paragraph (exhibit B):
“Not enough data are available to evaluate differences in the incidence and clinical features of aphasia in men and women. Some studies suggest a lower incidence of aphasia in women because they may have more bilaterality of language function. Differences may also exist in aphasia type, with more women than men developing Wernicke aphasia.”
“Prevalence and characteristics of men and women are expected to afasia is not enough information available. If afasia some studies, women work more, not less, because they show that the spoken language. There may be differences in the type of OST, women and men to develop more of a vernikke afasia, more.”
Although the B paragraph bears some resemblance to A, it is nearly impossible to determine its original meaning. This is similar to what happens to medical notes in most current EMRs (except the paragraph would be broken up with lab values and vital signs from the past week or two). If your job were to read hundreds of pages of B-type paragraphs all day, what do you think would happen? Would you enthusiastically adopt this new technology? Or would you give up reading the notes completely? Would you need to spend hours of your day finding “work-arounds” to correct the paragraphs?
And what would you say if the government mandated that you use this new technology or face decreased reimbursement for treating patients? What if you needed to demonstrate “meaningful use” or dependency and integration of the translator into your daily workflow in order to keep your business afloat? What if the scope of the technology were continually expanded to include more and more written information so that everything from lab orders to medication lists to hospital discharges, nursing summaries, and physical therapy notes, etc. were legally required to go through the translator first? And if you pointed out that this was not improving communication but rather introducing new errors, harming patients, and stealing countless hours from direct clinical care, you would be called “change resistant” or “lazy.”
And what if 68,000 new medical codes were added to the translator, so that you couldn’t advance from paragraph to paragraph without selecting the correct code for a disease (such as gout) without reviewing 150 sub-type versions of the code. And then what if you were denied payment for treating a patient with gout because you did not select the correct code within the 150 subtypes? And then multiply that problem by every condition of every patient you ever see.
Clearly, the cost of the EMR is the main reason why physicians are not willing to adopt them without complaint. Good riddance to the 50% of doctors who say they’re going to quit, retire, or reduce their work hours within the next three years. Without physicians to slow down the process of EMR adoption, we could really solve this healthcare crisis. Just add on a few mobile health apps and presto: we will finally have the quality, affordable, healthcare that Americans deserve.