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Latest Posts

Practice Variation: Essential To e-Patient Awareness

This is the first of the follow-up posts I hope to write from participating in the Salzburg Global Seminar titled “The Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care.”

One of our purposes on this site is to help people develop e-patient skills, so they can be more effectively engaged in their care. One aspect is shared decision making, which we wrote about in September. A related topic, from August, is understanding the challenges of pathology and diagnosis. Both posts teach about being better informed partners for our healthcare professionals.

I’ve recently learned of an another topic, which I’m sure many of you know: Practice variation. This is a big subject, and I’ll have several posts about it. It’s complex, the evidence about it is overwhelming, and its cost is truly enormous. Read more »

*This blog post was originally published at e-Patients.net*

Becoming A Savvy Healthcare Consumer: A “Difficult Science”

Dr. Kent Bottles is in the midst of a very thoughtful multi-part blog post under the heading, “The Difficult Science Behind Becoming a Savvy Healthcare Consumer.”

Part I examined “the limitations of science in helping us make wise choices and decisions about our health.”

Part II explores “how we all have to change if we are to live wisely in a time of rapid transformation of the American healthcare system that everyone agrees needs to decrease per-capita cost and increase quality.”

Both parts so far have addressed important issues about news media coverage of healthcare. Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Changing Patient Behavior: Two Power Words

“I recommend.” These are two word which, when spoken by a physician to a patient have tremendous power to change behavior. That assumes of course a trusting relationship between patient and physician (but that’s a topic for another day.)
 
Take the colonoscopy. The U.S. Preventive Services Task Force (USPSTF) recommends that adults aged ≥50 years get a colonoscopy every 10 years. In 2005, 50 percent of adults aged ≥50 years in the U.S. had been screened according to these recommendations. Not surprisingly, the rate of colonoscopy screening is much lower than that of other recommended adult preventive services. I was curious: Why?
 
Here are two interesting facts:

1. Studies show that patients cite “physician recommendation” as the most important motivator of colorectal screening. In one study, 75 to 90 percent of patients who had not had a colonoscopy, said that their doctor’s recommendation would motivate them to undergo screening.

2. In that same study, in 50 percent of patients where a colonoscopy was appropriate but not done, the reason given was that the physician simply did not “bring up” the subject during the visit. Reasons included lack of time, visit was for acute problem, patient had previously declined or forget. Read more »

*This blog post was originally published at Mind The Gap*

Understanding Treatment: The Communication Disconnect Between Doctors And Patients

Over the long week­end I caught up on some read­ing. One arti­cle* stands out. It’s on informed con­sent, and the stun­ning dis­con­nect between physi­cians’ and patients’ under­stand­ing of a procedure’s value.

The study, pub­lished in the Sept 7th Annals of Inter­nal Med­i­cine, used sur­vey meth­ods to eval­u­ate 153 car­di­ol­ogy patients’ under­stand­ing of the poten­tial ben­e­fit of per­cu­ta­neous coro­nary inter­ven­tion (PCI or angio­plasty). The inves­ti­ga­tors, at Baystate Med­ical Cen­ter in Mass­a­chu­setts, com­pared patients’ responses to those of car­di­ol­o­gists who obtained con­sent and who per­formed the pro­ce­dure. As out­lined in the article’s intro­duc­tion, PCI reduces heart attacks in patients with acute coro­nary syn­drome — a more unsta­ble sit­u­a­tion than is chronic sta­ble angina, in which case PCI relieves pain and improves qual­ity of life but has no ben­e­fit in terms of recur­rent myocar­dial infarc­tion (MI) or survival.

The main result was that, after dis­cussing the pro­ce­dure with a car­di­ol­o­gist and sign­ing the form, 88 percent of the patients, who almost all had chronic sta­ble angina, believed that PCI would reduce their per­sonal risk for hav­ing a heart attack. Only 17 percent of the car­di­ol­o­gists, who com­pleted sur­veys about these par­tic­u­lar patients and the poten­tial ben­e­fit of PCI for patients fac­ing sim­i­lar sce­nar­ios, indi­cated that PCI would reduce the like­li­hood of MI.

This strik­ing dif­fer­ence in patients’ and doc­tors’ per­cep­tions is all the more sig­nif­i­cant because 96 percent of the patients “felt that they knew why they might undergo PCI, and more than half stated that they were actively involved in the decision-making.” Read more »

*This blog post was originally published at Medical Lessons*

Minnesotans Get More Lower-Back MRIs: Why?

Kudos to Christopher Snowbeck and the St. Paul Pioneer Press for digging into new Medicare data to report that the state the newspaper serves is out of whack with the rest of the country in how many expensive MRI scans are done on Minnesotans’ bad backs.

Snowbeck artfully captures the predictable rationalization and defensive responses coming from locals who don’t like what the data suggest. Because what they suggest is overuse leading to overtreatment. So here’s one attempt a provider makes to deflect the data:

“The Medicare billing/claims data, which this report is generated from, would not capture conversations between a patient and provider that may have addressed alternative therapies for lower back pain,” said Robert Prevost, a spokesman for North Memorial Health Care. “It’s important to recognize the limitations of this data.”

No, data don’t capture conversations. But wouldn’t it be fascinating to be a fly on the wall during those many patient-physician encounters that led to an MRI to see what level of truly informed shared decision-making (if any) took place? Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Latest Book Reviews

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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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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