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Postoperative Care And “The Black Swan”

This is a guest post by J. Paul Curry, M.D.

I was inspired when I lost my best friend 15 years ago to a common medical-error phenomenon: The lack of monitoring patients in the hospital.

Losing Mark altered my entire career in medicine and started me on a long journey of trying to understand how this particular problem happens. The journey has been eye-opening for me for many reasons, and probably most importantly by striving to learn and understand how the human brain can deceive itself into believing that thoughtful, rational, goal-directed tactics are always the solution to finding the answers to highly-complex enigmas.

Actually, the blockbusting solutions that change the course of our culture — how we do things — are most often totally unpredictable and discovered by accident by disruptive innovators, such as Dr. Larry Lynn of the Sleep and Breathing Research Institute, willing to tinker on their own and against the grain of thousands of smart people who dismiss this kind of outlier work as fantasy. To get just how often this happens and why, I’d invite those unfamiliar with Nassim Nicholas Taleb’s work to read “The Black Swan : The Impact of the Highly Improbable” and other books of his. This is what we’re up against today.

I was recently operated on, having a significant multi-level back surgery at one of the outstanding university spine programs in the country, supported by one of the elite anesthesia programs. I was told by the resident that I’d be going to the general care floor following my surgery, where I’d be checked on regularly. This was a given because I’m a fitness fanatic, but the resident wasn’t prepared for my followup questions. As I probed for more detail, it became apparent that no one in the organization had any inkling that nursing checks only occurring every four or eight hours on a patient fresh from surgery with patient-controlled narcotics was less than standard of care.

I told them I have mild sleep apnea and wanted pulse oximetry at minimum. I had to be upgraded to telemetry to get it. What’s more interesting is that there was so little understanding of this problem that they put me on pulse oximetry in a room where the only one who could watch it was me — the patient. Read more »

The Physician Exodus: When Doctors Leave Hospitals Behind

My partners and I have long struggled with the lack of specialty back-up at our hospital. Semi-rural hospitals, out of the way facilities, just can’t always attract specialists. So, we’re happy to have cardiologists every night, but understand that we only have an ENT every third night. We’re thankful to have neurologists, even if they don’t admit anyone. We’re glad to have radiologists, even if they don’t read plain films after 5PM on weekdays.

Still, I continue to scratch my head about why only three of seven community pediatricians take call, such that family physicians have to admit their patients. I was bumfuzzled that our neurologists were previously going to require us to use telemedicine for stroke evaluation when their offices were close by the hospital. (In the same year they were called in roughly three times per neurologist for urgent stroke evaluation.) That problem was resolved, thank goodness.

Now, I find that the problem has returned and grown. We will, very soon, have no ophthalmologist on call, despite the fact that we have three in the community and that they are contacted with remarkable rarity to deal with on-call emergencies. Soon, we will have no neurologist on the weekend. And the pediatric problem remains.

Of course, I’m using my local experience to highlight something that isn’t a local problem at all. It’s a national problem. All over America, specialists are relinquishing their hospital priveleges and staying in the office. Proceduralists are opening surgery centers that are free from the burdens of indigent care. Primary care physicians are allowing hospitalists to do all of their admissions.

In the process, not only are patients losing out, but referral centers are being absolutely overwhelmed. The cities and counties that lie around teaching hospitals are sending steady streams of patients, since they have fewer and fewer specialists. Those referral and teaching centers want patients, but they can’t take all of the non-paying patients, all of the complicated, or even all of the mundane patients with no local coverage. Those facilities, for all their shiny billboards and “center of excellence” marketing, will collapse. Read more »

*This blog post was originally published at*

Family Physicians: Are They Paid Well Compared To Other Docs?

Here’s an interesting article, talking about stuff that’s not new to anyone who has read my blog for the last three years. The current relative value unit (RVU) system is a scam, perpetuated by a super-secretive group of subspecialists each  inflating their own worth for the benefit of themselves, at the expense of primary care.

If you don’t understand what I’m talking about, first read about RVUs explained. Then come back and read this article put out by the National Institute for Health Care Management. It’s titled “Out of Whack: Pricing Distortions in the Medicare Physician Fee Schedule.“ In his essay, Dr. Robert Berenson shows how distorted primary care specialties are paid, relative to other specialties, in an all Medicare practice with the equivalent input of hours worked. Read more »

*This blog post was originally published at The Happy Hospitalist*

Disease By Choice

“Why should I take my blood pressure medication,” you ask? The more I do this thing called hospitalist medicine, the more I appreciate the power of lifestyle choices we all make.

Every opportunity I get I give my patients my smoking lecture and charge their insurance  a CPT 99406. Everybody knows that smoking is bad for you and it causes lung cancer. Nobody knows all the other stuff. They’re always shocked.

Maybe it’s time for me to start a blood pressure lecture. I often have  patients who say: “Why should I take my blood pressure medication?” They always answer their own question with the same answer: “I was feeling fine. I didn’t see a reason to take my blood pressure medication.”

You see, these are people with insurance. These are people with the Medicare National Bank. These are people who don’t have to lift a finger or a dime to pay any out-of-pocket expenses for their healthcare. And yet, they still lack the motivation to care for themselves, even with incredible resources out there these days to help them — things like great online blood pressure chart sites for home monitoring.

Whatever the reason — whether it’s ignorance, laziness, lack of motivation, lack of remembering, or selfishness — people just don’t take care of themselves. Read more »

*This blog post was originally published at The Happy Hospitalist*

Hospital(ist) Food Service, Too?

What is a hospitalist and what kind of care does a hospitalist provide? It’s funny to read what people are writing these days about my professional role in patient care. It now appears hospitalists don’t manage medical issues anymore, but rather go through seven years of medical training to discuss the efficiency of the cafeteria food with their patients.

I read one article where the reader (obviously not a hospitalist) suggests that a hospitalist is a medical doctor who can do all the things normal doctors can, but instead of seeing patients all day, he makes rounds through the hospital, talking to patients to find out what can make their hospital stay better. And what kind of issues does the hospitalist deal with on their rounds? Why, the efficiency of the cafeteria food, of course.

I guess I was sleeping the day I was supposed to learn about the efficiency of hospital food in medical school. Maybe that means, after reviewing the SHM/MGMA 2010 hospitalist salary compensation report, I should request a pay cut because of my failure to provide cafeteria support. Or better yet, maybe I could make it up by asking security if I could provide takedown support on some code assists. Okay, I feel better about my role as a hospitalist.

*This blog post was originally published at The Happy Hospitalist*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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