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All Physicians Should Engage In Pharmaceutical Whack-A-Mole: Please Follow Physiatry’s Lead

Medical school prepares physicians to prescribe medications for prevention and treatment of disease, but little to no time is spent teaching something just as important: de-prescribing. In our current system of auto-refills, e-prescriptions, and mindless “check box” EMR medication reconciliation, patients may continue taking medications years after their original prescriber intended them to stop. There is no doubt that many Americans are over-medicated, and the problem compounds itself as we age. Although “no-no” lists for Seniors (a tip of the hat to the American Geriatrics Society “Beers List”) have been published and promoted, many elderly Americans are prescribed medicines known to be of likely harm to them.

You may be surprised to learn that one medical specialty has taken advanced steps to address this problem. Physiatry (also known as Physical Medicine and Rehabilitation or PM&R) is a national leader in pain management education, and is the author and promoter of  the majority of continued medical education (CME) courses on reducing opioid prescribing in favor of alternative pain management strategies. But did you also know that most patients who are admitted to an inpatient rehabilitation facility (IRF) are tested on their capability to correctly administer their own medications before they are discharged home?

The MedBox test provides a validated cognitive performance assessment of whether or not an individual can correctly distribute multiple prescription medications into weekly pill boxes as directed on the containers. This is a short video of how the test works, demonstrated by some occupational therapists having a good time with it. In one fell swoop, this test checks vision, reading comprehension, pharmaceutical knowledge, manual dexterity, attention, and short term memory.

This test is very helpful in picking up potential misunderstandings in how prescription meds are to be taken, and identifying cognitive deficits that might preclude accurate self-administration of prescription meds at home. One of our main goals in rehab is to make sure that patients have the skills, assistance, and equipment necessary to thrive at home, so that they can remain hospital-free for as long as possible. To that end, we feel strongly that limiting medications to those only truly necessary, as well as making sure that patients can demonstrate safe-use of their medications (or have a caregiver who can do this for them), can reduce hospital readmission rates, falls, unwanted drug side-effects and accidental drug-drug interactions.

In addition to MedBox testing, physiatrists invite hospital pharmacists to join their weekly patient team conferences. While we discuss patient progress in physical, occupational, and speech therapies, we also review nursing assessments of medication self-administration competency, and ask our pharmacist(s) which medications can potentially be stopped or decreased that week. Rehab physicians (familiar with patient health status, goals, and current complaints) and pharmacists together come up with stop dates and taper regimens at these weekly meetings.

Part of the reason why inpatient rehabilitation has been so successful at reducing hospital readmission rates, in my view, is that we are committed to pharmaceutical whack-a-mole. “Test-driving” patient competency at medication self-administration, in the setting of responsible de-prescribing in a monitored clinical environment, is a highly valuable (though sadly under-reported) benefit of rehabilitation medicine. I hope that my medical and surgical peers will join us physiatrists in combating some of the patient harms that are passively occurring in our healthcare system designed to add, but not subtract, diagnoses and treatments.

CMS “Never Events” Incentivize Physicians To Avoid Caring For High Risk Patients

In 2008, the Centers for Medicare and Medicaid Services (CMS) announced it would no longer pay for the treatment of “never events,” i.e., certain medical conditions in hospitalized patients which the Feds deem to be universally avoidable under all circumstances. These conditions included:

* Decubitus ulcers
* Two kinds of catheter-associated infections
* Air embolism
* Mediastinitis after coronary bypass surgery
* Transfusing patients with the wrong blood type
* Leaving objects inside surgery patients
* In-hospital falls

Then, having been delighted with the results of its original list (or dismayed that healthcare costs continued to skyrocket despite its original list) CMS subsequently proposed declaring several new conditions as “never events,” including: Read more »

*This blog post was originally published at The Covert Rationing Blog*

Book Review – Over the Edge: Death in Grand Canyon

Michael Gighlieri and Thomas Myers are coauthors of Over the Edge: Death In Grand Canyon, which is one heck of an interesting read. It is an encyclopedic rendition of all of the fatal accidents known (at the time of the writing) to have occurred in the Grand Canyon. The over-arching observation, made by the authors and almost certainly by the readers, is that the vast majority of these deaths were avoidable. Failure to recognize risk, or frank disregard for hazards, led to tragic loss of human lives. For every person who died, countless more suffered.

Early in the book and at intervals thereafter, the authors apologize for the graphic descriptions and for articulating the opinion that the fatalities were avoidable. They are apologizing for accurately observing that people can be uninformed, or informed and foolish. There is, of course, an element of risk inherent in many outdoor recreational activities, but the authors present an entirely different spin on risk – namely, unambiguously unnecessary risk. They are correct – too many people have paid the price, in the theme of this book, with loss of life and great emotional suffering (presumably) to family and friends.

There is a bit of adventure in the telling of tales, but this is not an adventure book. It is, rather, a series of accountings, some written in great detail and some more superficially. There is nothing boring about this book, but it is easily put down after a section is completed.

From the back cover: “Two veterans of decades of adventuring in Grand Canyon chronicle the first complete and comprehensive history of Grand Canyon misadventures. These episodes span the entire era of visitation from the time of the first river exploration by John Wesley Powell and his crew of 1869 to that of tourists falling off its rims today. These accounts of the nearly 600 people who have met untimely deaths in the Canyon set a new high water mark for offering the most astounding array of adventures, misadventures, and lifesaving lessons published between two covers. Over the Edge promises to be the most intense yet informative book on Grand Canyon ever written.”

The major and minor sections represent the categories of accidents: falls from the rims, falls within the canyon, heat illness (and dehydration), flash floods, river accidents (including crossings and drownings), air accidents, rockfall, envenomations, freak accidents, suicide, and murders.

The book is replete with lessons learned and safety advice – all of it useful for educators, adventurers, explorers, search and rescue personnel, and casual visitors. The book truly serves a purpose, which is to articulate history in such a way that the reader can learn from it, and hopefully, avoid the catastrophes that befell the unfortunate victims portrayed in these tales. Other interesting books co-authored by Dr. Myers are Fateful Journey – Injury and Death on Colorado River Trips in Grand Canyon and Grand Obsession – Harvey Butchart and the Exploration of Grand Canyon.

This post, Book Review – Over the Edge: Death in Grand Canyon, was originally published on Healthine.com by Paul Auerbach, M.D..

The Ultimate Criterion For A Hospital “Never Event”

As many of you know, I’ve been pretty upset about the “never events” policy put forward by CMS. That’s because they took a theoretically reasonable punitive rule (Medicare will not pay hospitals for patient care related to gross medical errors, aka “never events,” like wrong-side surgery) and made it far too general (never events include delirium, falls, and any infection – even a cold). It is absolutely impossible to prevent these sorts of things 100% of the time. So how should “never events” be defined?

The Happy Hospitalist nails it:

Can the never event happen at home? If the answer is yes, it cannot be a never event. It is a natural event. Even the criminal events that nobody can foresee are considered never events. Tell me how a hospital can prevent a random crazy family member or hospital guest from going berserk and assaulting an employee or patient. It’s impossible to predict or prevent.

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