August 11th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
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One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.
We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, “a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety.” More than 50 percent “of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs.” Approximately “one in nine said the harm that resulted was significant.” The respondents said that “if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely.”
This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient’s condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient’s condition and the rescue/environmental situation. If I can get a decent handle on a patient’s condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient’s initial assessment has underestimated the problem(s).
I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to “crash.” This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it’s my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.
Here are some simple rules to follow:
1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it’s important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.
image of leg splinting courtesy of www.princeton.edu
This post, Dropping The Ball In Patient Care: Provider Handoffs, was originally published on
Healthine.com by Paul Auerbach, M.D..
August 6th, 2009 by GruntDoc in Better Health Network, Health Policy, Opinion
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The Happy Hospitalist, generally an excellent blogger, wrote yesterday about how salaried docs must be delivering better care than those greedy FFS docs, because the Cleveland Clinic does a terrific job with docs on a salary. I suspect their excellent outcomes have nothing to do with reimbursement model and a lot more to do with systems and a strong gatekeeper model.
He totally missed the elephant in the room in the Big Group Clinic model: who gets the money for doing the work.
He cites as an example a GI doc who left the Clinic for independent practice and quadrupled his income. Let’s say he’s working as hard as he did in the Clinic; is he billing more than the Clinic did? I doubt the Clinic wasn’t billing the usual amount for the work, so 3/4 of this docs’ billing went where?
I suspect it went into the overhead of the Clinic. This isn’t a knock on them, it works for their group, so fine. Other groups do essentially the same thing. It’s legal and morally defensible, and some docs don’t mind being salaried.
Salaried docs in a big Multispecialty Clinic have different incomes, but not as radically disparate as the non-clinic model. As a way to somewhat equalize RVRBS issues it works (I wouldn’t want to be in the room when salaries come up, though).
What salaries do not do is get docs to work harder, see more patients. Some docs are very dedicated, motivated people who would work for rent and grocery money. Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder? As an incentive to produce nothing beats getting paid for it.
(This isn’t an endorsement of excessive or un-necessary procedures; there are greedy jerks in all professions).
Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less. Way less inter-group stress.
Salaries aren’t all bad, but they’re not the Key to Great Healthcare.
Discolsure: I’ve worked ED’s both ways, and much prefer fee for service.
*This blog post was originally published at GruntDoc*
July 29th, 2009 by KevinMD in Better Health Network, Opinion
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When it comes to opiate drugs, like morphine, there is a bitter debate between patients who are in chronic pain, and the doctors who are vilified for under or over-prescribing these medications.
But there are some other subtle influences that push doctors to prescribe these drugs, in some cases inappropriately. An ER physician talks about the issue, saying, “when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction. We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.”
There is also the pressure to provide “patient satisfaction,” and indeed, low scores in this area can place a doctor’s job in jeopardy. Taking a stand against those who inappropriately request opiates will result in low patient satisfaction scores, and “will often times result in arguments, profanity, and calls and letters to administration.”
What’s the answer? Perhaps a little less reliance on these scores, since a good patient satisfaction score is not necessarily correlated with proper medicine.
*This blog post was originally published at KevinMD.com*
July 28th, 2009 by Shadowfax in Better Health Network, Health Policy
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From the department of “Credit where it’s due,” in the comments of my
post on the Lewin Group, Nurse K pointed out the following:
Come on Shadowfax, you’re blogging about this stuff and you stand to make A TON of money if it goes through…for awhile…until insurance companies decrease your compensation since you’re making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.
Much as I (really, really) hate to admit it, she’s absolutely right. In fact, I’ll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn’t getting paid a thing for my efforts. I started keeping track of the number of uninsured I saw every day, just as a pet obsession. It was a sobering number. After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc. For me, this cause became something beyond the personal a long time ago and became a moral imperative.
But K is right to note the potential for bias, and it’s fair for me to acknowledge it. I hope that my integrity on this point is evident. The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn’t make me popular in EM circles!)
This is something which struck me yesterday, reading the med blogs reaction to Obama’s presser. Quite a few docs mounted their high horse and with great indignation denounced this:
Doctors are forced to make decisions based on a fee payment schedule that’s out there. So they’re looking… if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, “I’d make a lot more money if I took this kids tonsils out.” Now that might be the right thing to do, but I’d rather have that doctor making those decisions based on whether you need your kids tonsils out…
Now it’s a clumsy clinical scenario written by someone who has no clue about medicine. But it’s a damned fair point. Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more. It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab. It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).
Whether there’s a “fix” for that in the current reforms is debatable. It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified. I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests. The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point. Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.
*This blog post was originally published at Movin' Meat*
July 27th, 2009 by Nicholas Genes, M.D., Ph.D. in Better Health Network, News, Opinion
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Friends visiting New York City this summer keep asking if it’s safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.
I like to think my friends are pretty sharp, discerning folks (after all, they’re choosing my company) so I have to attribute these inappropriate questions to a wider problem.
For reference, here’s the latest and thought probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.
This deaths and hospitalizations are concerning, naturally, but some perspective is in order: as many as half a million New Yorkers have been infected with H1N1, and this spring in US cities, we actually saw a smaller fraction of deaths due to infectious respiratory illness, compared with 2008. Also, for reference, based on data from a few years ago, I’m guessing that any given three month period, there are between 10,000 to 15,000 deaths in New York City.
So why were ED’s swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:
…with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.
The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.
…The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.
All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process…
Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They’ve decided it’s just not in their interest.
I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.
There are many factors driving the public appetite for health risk information — and that’s understandable. I think it’s even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.
But what happened in NYC this spring was media malpractice — night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasion in which a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority — by the next day the lead story was ED’s are overcrowded and schools are closing.
EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.
But I’m more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.
It wasn’t enough to help ED’s this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It’s really the first good viral news I’ve heard in a while.
*This blog post was originally published at Blogborygmi*
One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.
