September 30th, 2009 by Happy Hospitalist in Better Health Network, Primary Care Wednesdays
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To be a great internist you have to be great at blood gas interpretation. And you have to be able to do it quickly and efficiently. You have to understand what all the numbers mean and you have to get a good clinical sense of how to interpret them and how to change management based on their result. And you have to be able to do it without pulling out your formula books. In six years as a hospitalist I have never calculated what the compensatory responses should be. I just know.
Sometimes blood gases change your management or your medical opinion on what’s happening. Take for example my patient with advanced MS. She presented through the emergency department with “oropharyngeal bleeding of unclear etiology”. Her original BMP:
Na 137
K 4.0
CL 99
HCO3 36
BUN 35
CR 1.0
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*This blog post was originally published at A Happy Hospitalist*
September 28th, 2009 by Happy Hospitalist in Better Health Network, Opinion
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I have blogged extensively about why standard of care is an irresponsible measure of the threshold for determining negligence in medical care. Most recently, I blogged about it
here and
here. Imagine for a moment what capitalism would be like if your investment adviser was sued every time your investment value went down. Imagine what life would be like if they risked civil liability every time a bad outcome occurred. What if no laws were broken? What if an after the fact determination of negligence was based on a bad outcome?
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*This blog post was originally published at A Happy Hospitalist*
September 25th, 2009 by Happy Hospitalist in Better Health Network, Humor, Opinion
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Over the last several weeks I have received numerous emails dictating the enforcement of work place rules regarding eating and drinking in nursing areas and other areas with patient charts. It seems everyone, from the Chief of Staff to the CEO to the Head Nurse In Charge has been making it very clear that drinking in work areas won’t be tolerated. I have at times been confronted by dutiful staff doing their jobs with a robust sense of confidence to enforce this potentially dangerous patient safety issue.
Or so I thought. Whilst speaking with one of Happy’s friendly colleagues, I learned that the issue of food and drink in the work place has nothing to do with patient safety. Like my colleague stated so eloquently, if there is data that can be presented to me that shows my action of drinking coffee at the work stations would some how harm my patient, I will gladly stop immediately. Discussion finished.
But as I learned from my colleague, the issue of food and drink at the nurse’s station or anywhere near patient charts has nothing to do with patient safety. In fact, the regulations are in place to protect ME from myself.
That’s right, the coffee Nazis are cruising the halls with reckless abandonment searching for violators of the hospital wide coffee ban on rounds not because patients could be harmed, but because I could harm myself.
You see, it turns out my distinguished colleague was told these regulations were not CMS or JCAHO regulations, but rather OSHA regulations.
So I looked it up
“OSHA does not have a general prohibition against the consumption of beverages at hospital nursing stations. However, OSHA’s bloodborne pathogens standard prohibits the consumption of food and drink in areas in which work involving exposure or potential exposure to blood or other potentially infectious material takes place, or where the potential for contamination of work surfaces exists 29 CFR 1910.1030(d)(2)(ix). Also, under 29 CFR 1910.141(g)(2), employees shall not be allowed to consume food or beverages in any area exposed to a toxic material. While you state that beverages at the nursing station might have a lid or cover, the container may also become contaminated, resulting in unsuspected contamination of the hands.
Here are the actual OSHA regulations
1910.1030(d)(2)(ix)
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
1910.141(g)(2)
Eating and drinking areas. No employee shall be allowed to consume food or beverages in a toilet room nor in any area exposed to a toxic material.
In other words this is not a patient safety issue, but rather an employee safety issue. The Joint Commission has no specific standard on the issue other than for hospitals to comply with OSHA regulations.
So with that in mind, I have two comments regarding the issue:
- As a private practice physician who is not employed by the hospital, I would suggest that these OSHA rules do not apply to me and therefore the hospital risks no retribution for noncompliance from the accreditation arm of the Joint Commission, which is why I suspect the issue comes center stage for hospitals everywhere. If necessary, I will gladly sign a waiver to relinquish my rights to compensation should I ever contract a blood born pathogen or other communicable disease from drinking my coffee.
- If the hospital believes this is a patient safety issue and wishes to make their regulations stronger than those of OSHA and apply them to ALL people in areas with patient pathogens, I will gladly relinquish my daily fluids when I am shown the data regarding patient harm AND the hospital also bans all patient guests from bringing food or drink into the patient’s room. If this is a patient safety issue, it must apply to everyone should they wish to make their rules stronger than OSHA guidelines.
Until this is resolved with rational thought, perhaps over a round of coffee, I’m going to carry one of these around:
It always seems to work for patients.
*This blog post was originally published at A Happy Hospitalist*
September 22nd, 2009 by Happy Hospitalist in Better Health Network, Opinion
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What’s wrong with using standard of care as the threshold of medical negligence? I walked you through a case, point by point, as to how the failure to diagnose cannot be considered negligence and why the process of the differential diagnosis must be protected from the fear based legal system we operate in.
When the differential diagnosis became a legal driven process, we physicians lost our ability to offer cost effective, clinical driven medicine. We became front seat drivers in the world’s largest Ponzi scheme known as the Medicare National Bank. A
99 trillion dollar black hole of defensive medicine.
What is it about the threshold of standard of care that makes it irrational? Why is that the standard for negligence? And what exactly is it? In six years of clinical hospitalist practice, three years of residency and four years of medical school, I have never taken a lecture, never seen a presentation, and never read a book about the mystical standard of care. In fact, I find myself grasping to comprehend exactly how to define its very existence.
The great legal resource,
Wikipedia, defines standard of care as
The requirements of the standard are closely dependent on circumstances. Whether the standard of care has been breached is determined by the trier of fact, and is usually phrased in terms of the reasonable person. It was famously described in Vaughn v. Menlove (1837) as whether the individual “proceed[ed] with such reasonable caution as a prudent man would have exercised under such circumstances.”
It goes on to define that reasonable caution as the
Bolam Test
Bolam v Friern Hospital Management Committee [1957] 1 WLR 583 is an English tort law case that lays down the typical rule for assessing the appropriate standard of reasonable care in negligence cases involving skilled professionals (eg doctors): the “Bolam test”. Where the defendant has represented him or herself as having more than average skills and abilities, this test expects standards which must be in accordance with a responsible body of opinion, even if others differ in opinion.
I see a problem with what the standard has become. If everyone in my community orders a head CT for drunks with altered mental status, that represents an action by a responsible body of opinion. Does it mean it’s the right opinion? It does not. When the body of opinion has been contaminated by a persistent and progress fear of litigation, the standard defies the evidence, and itself creates irrational bars of achievement that can never be sustained. The responsible body has itself become irresponsible.
If we are to be a science driven profession, we must be allowed to maintain our integrity, without the fear of legal retribution for failing to uphold the irresponsible responsible body of opinion. Our standards are no longer based on science. When everyone orders the CT scan in drunks with altered mental status, the standard itself has become unreasonable.
Yet the marked deviation of the standard of care from the science of care marches on.
I have argued that standard of care is a local phenomenon. It is what ever the local community of professionals says it is, as they are the responsible body of opinion. The standard for evaluating a pulmonary embolism in downtown Chicago is not the same as the standard in rural New Mexico as it is in the jungles of Africa.
A lawyer previously responded that the local community should not set the standard. They argued that the standard should be a national, or perhaps an international evidence based standard. If science is science, there is no reason to believe that evaluating a pulmonary embolism in the United States should be any different than it is in the jungles of Africa. The most important factor in medical decision making if often not the science but the way the science is practiced on a local level.
The
standard of care in
McAllen, Texas is not necessarily the same as the standard of care at the Mayo Clinic. Is the cost difference legally driven or is it money driven at the local level? I suspect the contribution from both is enormous. Some argue that we should practice as Mayo practices. Mayo may be cheaper, but it isn’t cheap. I would argue that even under their payment model as a large salaried multispecialty organization with economies of scale, the ability to practice defensive medicine still thrives. Who says what costs $8,000 in McAllen but costs $5,000 at Mayo couldn’t be done for $2,000 if the victory against defensive medicine was won? I suspect it could, if physicians weren’t held to irrational standards by the unreasonable
reasonable body of opinion.
If the standard in McAllen is to do a heart catheterization on everyone with chest pain, that is what the community has decided. If the standard of care at Mayo is to do a cardiac stress test, that is the standard at Mayo. If the standard in the African jungles is to do a history and physical, that is the standard in the African jungle? What is the right standard?
The right standard is the one that doesn’t get you sued.
Now, are all three standards of care based on science? No. They are based on what the community of physicians has decided should be done. There will always be a large disconnect between evidence based medicine and clinical medicine. It is not reasonable to do a CT scan to evaluate a pulmonary embolism in the jungles of Africa if that is not the standard, even if the evidence suggests otherwise. Clinical factors should always drive the medical decision making.
Some have argued the standard of care should be founded in evidence based guidelines and not local practice expectations from responsible bodies of opinion. Rarely are guidelines clinically relevant in the hundreds of decision trees physicians make every day in their diagnostic processes. Guidelines are based on studies with limited populations of patients whose neatly defined age groups have packaged disease processes. The realities of clinical medicine make many guidelines unworkable and unreasonable.
My post here is an example of the limited value of guidelines in the differential diagnostic process. Not only are the guidelines often not relevant, they are often contaminated by medical societies and other big businesses with a money driven agenda and stealth conflicts of interest.We must also remember that most guidelines are not based on science but rather based on
expert opinion. All physicians are experts in their scope of practice and their opinions should therefore carry the same weight as the opinions expressed on academic based guidelines. Those that believe national standards should exist to drive standard of care practices across the vast clinical spectrum lack an understanding of what it means to be a physician.
Some lawyers wish to believe that having X, Y, and Z data points means doing A, B and C. Some wish to believe that failure to do so represents negligence as a responsible body of opinion would have done so.
I have never been introduced to this responsible body of opinion. I have no way of speaking for their recommendations. We have local culture driving decision making. We have limited national guidelines often corrupted by external influences. We have a legal system, who’s negligence is based on responsible bodies of opinion, opinions which have been established by fear driven medicine.
So what exactly does it all mean? When I order a lab or a test or a procedure or an x-ray to make my clinical decision making, I don’t sit there and think to myself, “What is the standard of care?”
I think to myself, “What is my expected action or reaction from doing this? What am I trying to accomplish?” I have never been introduced to this elusive responsible body of opinion. I have never been invited to a luncheon. This responsible body has never asked me out for a drink. I have never gone on a date with this body. I have navigated through ten years of clinical medicine and I have never once been formally introduced to this all knowing body of opinion.
By establishing the threshold of negligence as a vague responsible body of opinion, a concept which few physicians have studied, few physicians can quantify and few physicians trust, we have built exactly what the medical-legal-industrial complex has prepared for us: A high volume, high supply, high demand, high cost fear driven reality that we all pay for with out of control health care inflation.
If you think Mayo care is cheap, the time has come to consider that even the highest quality, lowest cost centers in this country could reduce their utilization of health care resources by 1/3, 1/2 or more if the fear of civil retribution for failure to diagnose was taken off the shoulders of passionate and devoted physicians from all fields of training and they were allowed the freedom to employ their differential diagnosis skills in a manner consistent with scientific inquiry and not a legal driven fear.
The longer we deny the fear, the quicker the end will be here.
*This blog post was originally published at A Happy Hospitalist*
September 13th, 2009 by Happy Hospitalist in Better Health Network, Opinion
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How expected. The CEO of whole foods says that government is not the solution to out of control health care expenditures. He says we are. The American people are responsible for out of control health care expenditures. He preaches a life of personal responsibility, of personal choice and actions that lead to health. And what does he get for it?
Pragmatists on all sides of the health care question (and probably every political question) believe that, on the whole, human nature does not change, and we’ve got to fight or not fight the health care war with the citizenry we’ve got, not the one we wish we had. Utopians like Mackey, on the other hand, believe that public-policy debates are only a middle step in the real solution to our problems, which is to change human nature. The solution to our health care woes, Mackey seems to believe, is for all of us to become like him—hyper-rational in evaluating our options, hyper-responsible in following through on them, and devoted to healthy living (that plant-based diet!).
Yes, that is actually the solution, to become more hyper-rational in evaluating our options, hyper-responsible in following through on them, and devoted to healthy living. The fact that this commentator makes a mockery of personal responsibility, instead choosing to support couch potato, Chetoo eating, Oprah watching smokers with for all their health care needs because, well, that’s just what humans do, is pathetic.
If you want someone else to pay for your health care, be prepared to play by their rules. And the rules have to change. Or there won’t be any money for anyone.
Ninety-nine trillion dollars says so. Making humans entitled to the side effects of bad habits because that’s just what humans do is a race to the bottom mentality. It’s at the core of the finance
quandary. Encourage bad habits by paying for them, and you get bad habits. Nobody can sustain that model of third party financing.
Would you insure a house who’s participants stated up front they would burn it down? Would you insure a car from a driver who said he would intentionally drive it into a brick wall? If not, why would you buy insurance for people who intentionally did things we know destroys them?
The CEO of Whole Foods should be hoisted onto the podium next to Obama for all the world to applaud. Obama should declare a God given right to live healthy (and he should quit smoking for good) and a God given right to pay more for your insurance if you don’t. It’s about personal responsibility. It’s not about handing you a plate of free insurance and saying go smoke ’em if you got ’em.
*This blog post was originally published at A Happy Hospitalist*
