June 30th, 2008 by Dr. Val Jones in Opinion
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As newly minted physicians begin their residency training and clinical care responsibilities on July 1, hospitalized patients might expect a bumpy transition. At least, that’s been the urban legend – “don’t get sick in July!” But is that really true? Are patients at higher risk for medical errors at teaching hospitals in July?
Some say, “no” and some say “yes.” I’m in the “yes” category, and some research suggests that medication error rates do in fact increase in the month of July. In the “no” category we have Jerome Groopman, renowned Harvard physician and author of “How Doctors Think.” He simply says, “Today, most hospitals closely watch over interns.”
This is what I wrote in a previous blog post:
There are many ways that an intern can make mistakes, without ordering a single test or procedure, and under the full scrutiny of red tape regulations and documentation practices.
When an intern fails to recognize a life threatening condition and chooses to do nothing, or to let the patient wait for an extended period of time before alerting his or her team to the issue, serious harm can befall that patient. And that harm is not caused by inexperienced procedural technique, or ordering the wrong medicine – it’s caused by doing nothing. This “doing nothing” is the most insidious of intern errors – and it is not remedied by any form of hospital quality improvement initiatives. It is the risk that a hospital takes by having inexperienced physicians in the position of first responders. Interns gather large amounts of information about patients and then create a summary report for their supervisors. The supervisors (more senior residents) don’t have time to fact check every single case, and must rely on the intern’s priority hierarchy for delivering care.
But many hours pass between the time an intern examines a patient and when a supervising physician checks back in with that patient. And within that period of time, many conditions can deteriorate substantially, resulting in the loss of precious intervention time.
Dr. Groopman describes an experience from his own life in which a surgical intern (in July) correctly diagnosed his son with an intussusception
(twisted bowel) but then incorrectly determined that the baby could wait to go to the O.R. Of course, untreated intussusceptions are nearly always fatal, and each minute that passes without intervention can increase the risk of death.
And so, in my opinion, it is in fact more dangerous to be admitted to a teaching hospital in July, but not necessarily for the reasons that people assume (procedures performed by inexperienced physicians or drug errors – though those mistakes can be made as well). Rather, it is because interns don’t have the clinical experience to know how to prioritize their to-do lists or when to notify a superior about a patient’s health issue. Timing is critically important in quality care delivery – and that variable is not controlled by our current intern oversight system.
Now that I’ve completely terrified you – I will offer you a word of advice: designate a patient advocate for your loved one (or yourself) if you have to be in the hospital as an inpatient (especially in July). If you can, find someone who is knowledgeable about medicine – and who knows how to navigate the hospital system. A nurse, social worker, or physician are great choices. That person will help you ensure that concerns are prioritized appropriately when your intern doesn’t yet fully appreciate the dangers behind certain signs symptoms. If you have no advocate, then befriend staff members who are particularly caring and experienced. Be very nice to them – but don’t be afraid to insist on being examined by the intern’s supervisor if you really are concerned. Unfair as it may seem, sometimes the most vocal patients get the best care.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 30th, 2008 by Dr. Val Jones in News
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I read a touching story at the BBC news center about a young woman with Alpert’s Syndrome. This rare syndrome is present in only 1 in 170,000 births. It results in facial disfigurement and mitten-like hands.
The physical defects of Apert’s syndrome were first described by Fredrick Apert in 1942. These characteristics include: A tower-shaped skull due to craniosynostosis (premature fusion of the sutures of the skull)—an underdeveloped mid-face leading to recessed cheekbones and prominent eyes, malocclusion (Faulty contact between the upper and lower teeth when the jaw is closed) and limb abnormalities such as webbing of the middle digits of the hands and feet.
Bones of the fingers and toes are fused in Alpert’s infants giving a “mitten-like” appearance of their hands. Children with Apert’s syndrome can have unusual speech characteristics such as hyponasal resonance due to an under-developed mid face, small nose and long soft palate and, sometimes, cleft palate.
What struck me about the girl’s story was how she described how it felt to be teased growing up, and how the worst part of the teasing was that no one stuck up for her. I’ve seen kids do this kind of thing before, and I can imagine how painful it is when no one has the courage to go to bat for you. I’ve often wondered how “doing nothing” to defend a little one might be just as bad as actively harrassing them. I’d encourage parents to teach their children not to tease others, and beyond that, to come to the defense of those being teased. I bet this will do a lot of psychological good for the victims.
The good news in this case is that the girl has had some very successful reconstructive surgery and has a fairly normal life. The teen is even thinking about boyfriends, and preparing for college. Many thanks to the surgeons who did such a wonderful job.
And coincidentally, the Happy Hospitalist brought this story to my attention: a 4 month old kitten was in a horrible accident that resulted in her losing the front half of her face. Veterinarians were able to save her life, though she remains quite deformed. I am told that the kitty is not in any pain, and is enjoying her life as a therapy pet. She brings hope to those recovering in the hospital from surgeries and serious illnesses. I suppose they see her as a loving animal who is cheerfully going about her kitty business, without giving much thought to her previous injury.
These stories of hope are made possible by the surgeons and veterinarians who devote their lives to saving face. In so doing, they provide the rest of us with valuable lessons, and new friends of exemplary courage.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 25th, 2008 by Dr. Val Jones in Expert Interviews, Health Policy
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My husband’s brother is a police supervisor in Rochester, New York. I guess that gives new meaning to “brother-in-law?” Sorry, bad joke. But on a more serious note, I recently had the chance to interview him about his work experience with the mentally ill.
What surprised me about our discussion is that his perspective on life, as a law enforcement officer, seemed to mirror that of the physicians I know. He touched on the rampant lack of personal responsibility in this country, and how HIPAA rules can lead to unintended consequences (like endangering neighborhood children). I’m grateful that men like my brother-in-law are willing to put up with the seedier side of life every day, so that others can enjoy a reasonably safe existence. See what you make of his point of view. Do you see parallels with medical practice?
Dr. Val: What sort of interaction do you have with mentally ill individuals? Are you trained to handle them differently?
Sergeant Zlotkus: People call us all the time to complain about individuals with certain mental disorders – either for bizarre behavior or for being threatening and disruptive. We have daily contact with local mentally disturbed individuals so we generally know which ones have the potential to be violent. We also have an EDPRT (Emotionally Disturbed Person Response Team) that is trained to deal with the mentally ill. The usual police response of just “going in and getting yes or no answers” doesn’t work well with a disturbed person who doesn’t know how to handle emotions. There are times where reaching out to grab someone’s wrist can cause them to go berserk and bang their heads on your police car.
More and more people with mental health issues [that cause violent behavior] are being released into the public and officers are getting hurt. People often think that the police are not dealing with the issue because they see the same people on the streets again and again. The fact of the matter is that we take them into detention but once they’ve been evaluated in the hospital, the mental health professionals choose to deal with them as outpatients and they’re right back out in the community again. We can’t put these people in jail, and knowing what to do with them can be a really tough judgment call.
Where do you draw the line? Just because you’re annoyed with someone’s actions – is that enough to lock them up? If a person paces back and forth in front of your drive way four hours a day, does that mean they have to be taken away by the police? What if that’s their only offense and the other 20 hours of the day they are fine?
How do we make this situation better?
Sgt. Zlotkus: What would really help is community education – it’d be great if we could let people know about certain individuals, and whether or not their unusual behaviors should be cause for alarm. For example, a young man with autism might be treated with understanding and tolerance when he expresses unusual behaviors, but a person with a history of mental disorders and violence should be viewed with caution. People should have a lower threshold for requesting police intervention in that case. However, because of HIPAA, we’re not permitted to let anyone know anything about others mental health or potential risks to their family.
Dr. Val: Does HIPAA affect police safety?
Sgt. Zlotkus: Absolutely. We are not allowed to save data related to individuals’ health information – so that when known drug users (who have Hepatitis C) are arrested they may try to spit on us or bite us to transfer their infection.
We’re told to use “universal precautions” with everyone – but it’s simply not practical to go into every situation with face masks and rubber gloves. It’d be really helpful if we could protect ourselves and others with the knowledge of what the risks really are.
Dr. Val: Is burnout a problem in the police force?
Sgt. Zlotkus: I’ve been a police officer for 18 years. Two of my close colleagues committed suicide during that time period. There is a sense of burnout or frustration that we all get after a while because we see the same people committing crimes over and over again. Since I’ve been working the same beat for so long, I’ve actually seen three generations of dysfunction in certain families. The drugs and violence are transferred from parents to children and it perpetuates itself. Also, people call 911 for the silliest problems and we need to respond. One woman called us because her 5 year old was having a tantrum. I felt like telling the woman to put her child in the corner and give him a time-out – what are the police supposed to do about it?
The overuse of the police force by a small minority of people who know how to work the system can be frustrating. Some people bump their lip and then have EMS, the fire department, and the police department show up and take them to the ER. When you see the abuse of the system over decades, it can really wear on you.
Dr. Val: What would improve your work life? More funding for more police?
Sgt. Zlotkus: That’s a tough question. On the one hand it would be great to have more police helping with all the work, but on the other, if we doubled the police force and were able to arrive at every request within 60 seconds, there would be a whole new batch of people ready to call us for their every whim. More police would just mean more abuse of the system.
Dr. Val: What’s the biggest problem facing police today?
Sgt. Zlotkus: Nobody wants to take responsibility for their own actions. They want to blame others, sue anyone they can, or just let the government take care of them. Most people just don’t know what it means to be a good citizen anymore.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 20th, 2008 by Dr. Val Jones in Health Policy
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I’ve collected a few reports from my fellow bloggers that perfectly exemplify healthcare improvement/payment strategies designed by committee.
A nonsensical quality assurance program in Britain, via GruntDoc:
Britain’s nurses are to be rated according to the levels of care and empathy they give to patients under government plans. Health Secretary Alan Johnson told the Guardian newspaper that he wants the performance of every nursing team in England to be scored.
But he ruled out rating individual nurses and also said it would not affect pay.
Ridiculous medical record documentation rules via the Happy Hospitalist:
The E&M rules of documentation state very clearly what type of information is required on follow up cognitive care visits. They state that you need to include things like character, onset, location, duration, what makes it better or worse, associated signs or symptoms.
This is all fine and dandy when you can quantify a complaint (like pain, rash, headache, or weakness). But what do you do when a chief complaint does not involve a qualitative or quantifiable entity? There are no E&M rules that allow exceptions to these circumstances. So you get the following garbage:
Chief Complaint: Hypercalcemia [too much calcium in the blood]
HPI: She presented with hypercalcemia. It is described as chronic, constant, and parathyroid. The symptom is gradual in onset. The symptom started during adulthood. The complaint is moderate. Significant medications include lithium. Important triggers include no known associated factors. The symptom is exacerbated by dehydration.
There is not a single piece of information in that excert that was clinically worth anything. In fact, it reads as if it is computer generated with key word insertion.
Character: Moderate (what does that mean?)
Onset: adult hood (what the hell)
Location: parathyroid (seriously?)
Duration: chronic and constant and gradual in onset.(what a bunch of garbage)
What makes it worse?: nothing and dehydration in the same paragraph, completely contradicting each other.
Imagine how much time was spent entering this worthless information. Not only asking them but entering them into the computer. Imagine multiplying this by 25 times a day. And you wonder why health care is so inefficient. Because we have to ask completely meaningless questions to get paid.
A new way to thwart physician compensation via the Physician Executive:
According to a June 11 CMS announcement, doctors will have to reconcile their NPI data with their IRS legal name data in order to get paid.
It is a befuddling regulation since, as an employed physician, 100% of my billings have gone to organizations that paid me a salary. Why check my provider identifier with my tax information? They don’t correlate. I can pretty much promise you that they never have and sometimes the discrepancies have been fairly substantial.
I am sure this will be a huge problem for docs in practice who bill under their name and get paid directly. Any discrepancy in any character in the field will ensure non-payment. This is not the kind of thing your laptop spell check will prevent. If this regulation is enforced to the letter, it will assure that services are provided free of charge.
I bet that this billing “error” can also be enforced as fraud and abuse, leading to criminal charges, financial penalties, and time in jail.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 18th, 2008 by Dr. Val Jones in Expert Interviews
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Currently, women make up about 15 percent of the active duty forces in Iraq and Afghanistan and by the year 2020 one in five young veterans will be female. Walter Reed and other Veterans Affairs (VA) hospitals are treating more and more injured women than ever before – but are these hospitals prepared to handle all the distinctively female health issues that will be coming their way?
This is the subject of a CBS news segment being released tomorrow night, June 19th. The producers gave me an early head’s up so that I could alert my readers to it, and I immediately reached out to Revolution Health expert, Dr. Iffath Hoskins, for comment.
Dr. Hoskins is well-versed in both military healthcare and women’s health. She completed an obstetrics and gynecology residency at the National Naval Medical Center in Bethesda, Md. and a maternal fetal medicine fellowship at the Uniformed Services University of the Health Sciences. (This includes the National Naval Medical Center and the Walter Reed Army Medical Center in Washington, D.C.). She has been the Chair and Residency Director of the Department of Obstetrics and Gynecology at the New York University Downtown Hospital, and the Chief of Obstetrics at Bellevue Hospital. She currently serves as the Senior Vice President, Chairman and Residency Director in the Department of Obstetrics and Gynecology at Lutheran Medical Center in Brooklyn, N.Y.
Dr. Val: What sort of gaps in care will women military personnel encounter at the VA?
Dr. Hoskins: First of all, the gaps in care are not only for women personnel, but there are gaps in care for all personnel due to resource constraints at the VA hospitals. When the VA system was originally conceived there was no need to support women’s health services as very few women worked as full time military personnel. Now about 15% of military personnel are women. Of course, women have many of the same sorts of health problems as men (migraine headaches, high blood pressure, heart disease, etc.) and the VA system is adept at handling those concerns. But when it comes to female reproductive health, contraception, pregnancy, and disorders of menstruation, the VA system is simply not equiped to handle that.
Dr. Val: How can the VA adapt to serve this influx of women veterans?
Dr. Hoskins: First of all the VA needs to recognize the unique needs of women and identify personnel within the VA system who are capable of meeting these needs. Even in the field some of the rules surrounding uniform requirements have not been adapted to suit the needs of women. During wartime and/or deployments, resources for menstruating women (eg private toiletries, contraception, etc) were scarce. So, the women often bled onto their uniforms and this created problems with personal hygeine.
Dr. Val: Does the VA treat military wives and daughters? What sort of care are they currently getting and could women soldiers benefit from those services?
The VA does not treat dependents because they were designed to meet the healthcare needs of individuals returning from serving their countries in a wartime model. TRICARE is the coverage provided to them and many large hospitals and clinics accept this insurance nationwide.
Dr. Val: Do you think that physical disfigurement affects women differently than men?
Dr. Hoskins: I don’t believe that this is an issue. Women soldiers are tried and true professionals. They know that they are in the military to serve their community, unit, battalion, company, and country and have accepted the potential consequences of death and disfigurement. After working closely with these women for 26 years, I know that they consider themselves soldiers, sailors, marines, and airmen first and foremost and are committed to doing whatever is expected and required of them.
When I was deployed in Operation Iraqi Freedom as one of the highest ranking Reserve Marine physicians, I conducted a research survey to explore the reactions of returning veterans to the large number of women involved in the operation. We asked them how they felt about having women living and working with them shoulder-to-shoulder in times of war, and whether it made a difference to the completion of the mission. We surveyed about 8000 military personnel, and 40% of them expressed concern about having women on the battlefield.
Dr. Val: What specific concerns did they have?
Dr. Hoskins: The respondents believed that the physical load and demand on the young men was greater than on the young women. Sometimes this wasn’t because of differences in physical strength but culturally the men wanted to help the women with their loads, and the women sometimes resented the help.The respondents noted that women who needed to retrieve their fallen comrades behaved differently than their male peers (the women were more likely to cry, which was frowned on by the men). Because the women and men were segregated in their sleeping quarters, accounting for everyone’s whereabouts became more difficult.
Overall the survey clearly showed that there was never a concern about whether or not the women were weapons-qualified. The respondents did not believe that the presence of women affected the success of their mission – but it certainly created distractions.
*Listen To The Podcast With Dr. Hoskins*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
