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Living Your Best Life, Even In The Hospital

My patient was an elderly farmer with severe vascular disease. He had advanced leg artery narrowing, had survived multiple heart attacks, and was admitted to the hospital after a large stroke. He was incredibly cheerful, vibrant, and optimistic. He had a very large, loving family who took turns attending to him, and encouraging him with each small improvement in his leg and arm strength. They knew his neurological exam better than his doctors.

I was amazed at his recovery, given the size and location of his stroke (and his advanced age), I had suspected that he would end up wheelchair bound. But he was determined to walk again and get back to his gardening as soon as possible. His children told me that he was very stubborn and was a true “fighter.” As their patriarch, he carefully questioned each of them about their goings on, making sure that they were each on track with grain harvesting plans, animal feedings, and various farm-related projects. His life had meaning and purpose, and the hospitalization was merely a change of venue for his daily instructions.

Because my patient was so motivated, I offered to bring him to his physical therapy session early one day. To my surprise, he firmly, but politely declined.

“I have an appointment with my family in my room.” he said.

I wondered if they were going to discuss advanced directives with an attorney, or something of similar seriousness.

“Oh, I see. Well we will come get you at the regular time then.” I smiled and left the room.

As I walked down the hall back towards the nurses station I recognized various members of his family proceeding towards his room, dressed in what appeared to be their “Sunday best.” There must have been at least 15 people in the group, ranging from tweens to adults. They were smiling and upbeat.

Minutes later I heard wondrous a capella choral sounds wafting from the patient’s room and filling an entire wing of the hospital. All motion ceased. Therapists stopped pushing wheelchairs, exercises paused, patients with walkers stood silent in the middle of sterile, tiled floors.

My patient had delayed his therapy session for something far more important – a live chorus of loving family, singing for him in a private exhibition that managed to touch us all.

The music I heard that day taught me a very important lesson. Some people know how to live their very best, wherever they are. Even a life-threatening condition in a hospital setting cannot dampen the human spirit.

May we all aspire to have such a spirit.

Cartoon: Why Are Hospitals So Noisy?

More Unintended Consequences Of Digital Data: How An EMR Gave My Patient Syphilis

I used to be a big believer in the transformative power of digital data in medicine. In fact, I devoted the past decade of my life to assisting the “movement” towards better record keeping and shared data. It seemed intuitive that breaking down the information silos in healthcare would be the first logical step in establishing price transparency, promoting evidence-based practices, and empowering patients to become more engaged in their care decisions. Unfortunately I was very wrong.

Having now worked with a multitude of electronic medical records systems at hospitals around the country, one thing is certain: they are doing more harm than good. I’m not sure that this will change “once we get the bugs out” because the fundamental flaw is that electronic medical records require data entry and intelligent curation of information, and that becomes an enormous time-suck for physicians. It forces us away from human interaction, thus reducing our patients’ chances of getting a correct diagnosis and sensible treatment plan.

How bad is it? The reality on the ground is that most hospitals are struggling enormously with EMR implementation. There are large gaps in the technology’s ability to handle information transfer, resulting in increased costs in the hundreds of millions of dollars per small hospital system, not to mention the tragically hilarious errors that are introduced into patient records at break neck pace.

At one hospital, the process for discharging a patient requires that the physician type all the discharge summary information into the EMR and then read it into a dictation system so that it can be transcribed by a team in India (cheaper than US transcription service) and returned to the hospital in another part of the EMR. The physician then needs to go into the new document and remove all the typos and errant formatting so that it resembles their original discharge summary note. In one of my recent notes the Indian transcriptionist misheard my word for “hydrocephalus” and simply entered “syphilis” as the patient’s chief diagnosis. If I hadn’t caught the error with a thorough reading of my reformatted note, who knows how long this inaccurate diagnosis would have followed the poor patient throughout her lifetime of hospital care?

Another hospital has an entire wing of its main building devoted to an IT team. I accidentally discovered their “Star Trek” facility on my way to radiology. Situated in a dark room surrounded by enough flat panel monitors to put a national cable network to shame, about 40 young tech support engineers were furiously working to keep the EMR from crashing on a daily basis – an event which halts all order processing from the ER to the ICU. Ominous reports of the EMR’s instability were piped over the entire hospital PA system, warning staff when they could expect screen freezes and data entry blockages. Doctors and nurses scurried to enter their orders and complete documentation during pauses in the network overhaul. It was like a scene from a futuristic movie where humans are harnessed for work by a centralized computer nexus.

At yet another hospital, EMR-required data entry fields regularly interrupt patient throughput. For example, a patient could not be given their discharge prescriptions without the physician indicating (in the EMR) whether each of them is a tablet or a capsule. As patients and their family members stand by the nursing desk, eager to be discharged home, their physician is furiously reviewing their OTC laxative prescriptions trying to click the correct box so that the computer will allow the transfer of the entire prescription list to the designated pharmacy. When I asked about the insanity of this practice, a helpful IT hospital specialist explained that the “capsule vs tablet” field was required by Allscripts in order to meet interoperability requirements with our hospital’s EMR. This one field requirement probably resulted in hundreds of extra hours of physician time per day throughout the hospital system, without any enhancement in patient care or safety.

For those of you EMR evangelists in Washington, I’d encourage you to take a long, cold look at what’s happening to healthcare on the ground because of these digital data initiatives. My initial enthusiasm has turned to exasperation and near despondency as I spend my days as a copy editor for an Indian transcription service, trying to prevent patients from being labeled as syphilitics while worrying about whether or not the medicine they’re taking is classified as a tablet or a capsule in a system where I may not be able to enter any orders at all if the central tech command is fixing software instability in the Star Trek room.

Dr. Val, The Traveling Physician: Living La Vida Locums

On Assignment In Idaho

It’s been a couple of months since my last post because I’ve been traveling around the United States working as a locum tenens (in Latin, “place holder” – a more elegant name than “temp”) physician. We’ve all heard of traveling nurses, but more and more physicians are also “living la vida locums,” as it were. There are actually over 100 agencies who find/provide temporary physician coverage for hospitals who need to fill gaps in their full timers’ schedules. You can find out more about these agencies at their trade organization site, the National Association of Locum Tenens Organizations (NALTO).

For those of my peers who’ve been curious about locums work, but haven’t tried it, I thought I’d provide you with some personal thoughts and insights in the form of Q&A. Please feel free to ask your own questions in the comments section and maybe we can generate a nice, interdisciplinary discussion about locums work. I’d love to hear from others who have worked locums!

Q: Why should I work as a locum tenens physician?

If you don’t mind travel and are a fairly adaptable individual (i.e. can learn new EMR systems, staff idiosyncrasies, and navigate hospital politics without excessive angst), then you can expect to make at least 33% more in salary working as a locum (with professional liability insurance, housing and travel covered included). In addition, you have no administrative or teaching responsibilities, coding/billing hassles, or staff management issues. You’re paid an hourly rate for a minimum number of hours, with overtime negotiable. You get to see different parts of the country, and can control where you go and how much you work. (E.g. Summers in Sonoma, winters in Florida… not a bad lifestyle choice.)

Q: What kind of physicians do locums work?

In my experience, there are four kinds of people who do locums work: 1) Retirees – those who have essentially retired from full time medicine and want to keep their hand in clinically without overwhelming responsibilities and work hours 2) Salary Seekers – those who want to make 33-50% more salary and don’t care where they live to do it (they work 22 days/month or more as a locums doc) 3) Dabblers – those who want to work part time because they are busy with another job or family responsibilities and 4) Problem People – those who have personality issues and/or a legal history that make it difficult to hold down a regular job.

I don’t know the relative numbers of these 4 subtypes of physicians who do locums, but I’d guess that 20% are Retirees (Rs), about 10% are Salary Seekers (SS’s), 60% are Dabblers (D’s), and 10% are Problem People (PP’s). I’m a D, and I have met Rs, SSs, and PPs on the work circuit. I’ve also spent time talking to internists and specialists who work as locums physicians so I have an idea of what others outside my specialty are up to.

Q: What’s the difference between locums agencies?

Each locums agency has its own “corporate culture” and some are more attentive to their physicians than others. For example, when you’re traveling en route to an assignment and your flight gets cancelled on a weekend, you suddenly realize how nice it is to have a responsive agency to help with travel triage. Choosing an agency is more than just finding the one that offers the best hourly wage, it’s about how they choose and negotiate with clients (hospitals), how many staff they have to help with payroll and travel, and if the recruiters themselves are patient and attentive. All of this is primarily learned by trial and error – alas. And I think it’s probably time to create a “Yelp” destination of sorts for physicians who are interested in locums work. I wish I had had one!

That being said, what I’ve learned is that agencies vary A LOT in what they offer you and that there is usually about 25% wiggle room in hourly rate negotiation, especially for highly-sought after specialties such as Internal Medicine. In one case, a client (hospital) confirmed to me that two different locums agencies presented the same candidate to them – one was charging $90/hour more for the physician, but the physician had been quoted the same hourly rate by both agencies.

One would think that there would be an advantage to being represented by the “Platinum level” locums agency because they’d negotiate higher pay rates for you, but what happens is that they negotiate high pay rates and then don’t pass it along. In the end, the only hospitals that use those companies are ones who’ve exhausted every other avenue. So if you work for a Platinum agency, you end up with an average salary working in the most difficult situations (i.e. where no one else would go and the hospital, in an act of desperation, had to pay through the nose for you.) In addition, I’ve had a Platinum agency take 3 months to pay me, whereas another agency regularly turned my time sheet into direct pay in 7 days.

So be forewarned – the biggest, shiniest agency might not be your best bet.

Unfortunately, smaller agencies (who may be more generous with salary rates) sometimes suffer from skeleton crew staffing and fall short of being able to triage travel disasters and manage client-related problems (e.g. the hospital said you’d see 12 patients a day but when you arrive they ask you to see 24) as needed.

When it comes to a locum agency, you want someone who’s not too big, not too small, and where you can establish a relationship with a recruiter who is responsive and smart. I cannot stress this enough. Your recruiter is your lifeline while you are on the job. Recruiters don’t just spend their time finding physicians to fill positions, they are the key point of contact between you and the hospital where you work. Their role is to lobby for you, and keep the hospital accountable for your work load and work environment. If the hospital promised that you’d only need to see X number of patients/day, then your recruiter is the one to hold them to that standard. If you are concerned about patient safety because staff members are incompetent in some way, then (believe it or not) your recruiter will convey those concerns to the hospital and get the problem solved.

So overall, your locums experience depends on the corporate culture of your agency, the size and number of travel/credentialing staff they have available 24/7, and the quality of recruiter assigned to your case.

In my next post I’ll cover the following questions:

Q: Where are the most favorable locums jobs?

Q: How can I negotiate the best salary?

Q: How do locums agencies decide how to match you with a given job opportunity?

Q: What is the licensing and credentialing process like? How do I make it easier?

When Is The Right Time To Tell Patients The Truth?

Although most doctors say they believe in the immediate free flow of information from physician to patient, the reality is that many hospitalized patients don’t receive a full explanation of their condition(s) in a timely manner. I’ve seen patients go for days (and sometimes weeks) without knowing, for example, that their biopsy was positive for cancer when the entire medical staff was clear on the diagnosis and prognosis. So why are patients being kept in the dark about their medical conditions? I think there are several contributing factors:

1. Too many cooks in the kitchen. During the course of a hospital stay, patients are often cared for by multiple physicians. Sometimes it’s unclear who should be the first to give a patient bad news. Should the news come from their primary care physician (who presumably has a long standing, trusting relationship with the patient) or the surgeon who removed the mass but doesn’t know the patient well? In many cases each assumes/hopes the other will give the patient the unpleasant news, and so the patient remains in the dark.

2. Family blockades. It often happens that a patient’s spouse or family member will request that news of an unpleasant diagnosis be delayed. They argue that it would be best for the patient to feel better/get stronger before being emotionally devastated by a test result. In some cases the family may be right – grief and shock could impair their participation in recovery efforts, resulting in worse outcomes. Cultural differences remain regarding how patients like to receive information and how families expect to be involved in care. American-style, full, immediate disclosure directly to the patient may be considered rude and inappropriate.

3. Uncertainty of diagnosis. Sometimes a clear diagnosis only develops with time. Biopsy results can be equivocal, the exact type of tumor may be unclear, and radiology reports may be suggestive but not diagnostic. Some physicians decide not to say anything until all the results are in. They cringe at the prospect of explaining uncertainty to patients, and without all the answers they’d rather avoid the questions. What if it looks as if a patient has a certain disease but further inquiry proves that she has something else entirely? Is it right to frighten the patient with possibilities before probabilities have been established?

Although sensitivity must be applied to the nuances of individual care scenarios, my opinion is that patients should be immediately informed of their test results and their physician’s thought processes at every step along the diagnostic pathway. Family member preferences, however well-meaning they are, cannot trump the individual’s right to information about their health. If physicians are unclear regarding which of them should break the news to a patient then they should confer with one another and come up with a plan ASAP.

The right time to tell the patient the truth is: now. To my colleagues who avoid giving patients information because it is personally uncomfortable (often leaving me or other third party to be the messenger), I have two words: “man up.”

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