September 17th, 2007 by Dr. Val Jones in News
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Physicians have known for at least 40 years that infectious bacteria (like staphylococcus aureus) can be transmitted on clothing. And now, as part of a comprehensive plan to reduce hospital infection rates, Britain’s National Health Service has recommended against physicians wearing white coats.
An interesting research study showed (back in 1991) that the dirtiest part of physicians’ coats are the sleeve tips and pockets. But surprisingly, coats that were washed at 1 week intervals and coats that were washed at 1 month intervals were equally capable of transmitting bacteria. Now that multi-drug resistant bacteria have become so common, they too can hitch a ride on coat sleeves and make their way from patient to patient.
During my residency, I clearly remember being horrified by the grunge I saw on my colleagues’ coats, all hanging up together on hooks outside the O.R.s. and in various parts of the hospital. I used to wonder if they were spreading diseases – but comforted myself that many bacteria need a moist environment to survive – so while the coats were certainly filthy, by and large they were not moist. Unfortunately my self-comfort was somewhat ill conceived – gram negative bacteria (like E. coli) do indeed need moisture for survival, but many viruses and gram positive bacteria (they usually live on the skin) do just fine in a dry environment. Other studies have confirmed that stethoscopes also carry a high bacterial load if not cleaned between patients. In fact, in reviewing some research studies for this blog post, I found that researchers have analyzed everything from hospital computer keyboards, to waiting room toys and patient charts. Infectious bacteria have been cultured from each of these sites.
Which leaves me to wonder: can we ever create a sterile hospital environment? Not so much. Although I agree that infections can be spread by white coats, and that a short sleeved clothing approach might help to reduce disease spread, I’d like to see some clear evidence of infection rates being reduced by not wearing coats before I’d prescribe this practice uniformly (pun intended). Bacteria can be spread on any type of clothing, by blood pressure cuffs, by stethoscopes, by dirty hands, by hospital charts… and we certainly can’t dispose of all of these. What would be left?
White Coat Rants (a wonderful new ER blog) describes the “ER of the future” – adhering to all the possible safety concerns of oversight bodies. Take a look at this whimsical perspective on what it would take to make the Emergency Department truly “safe” and imagine what it would take to make the hospital totally sterile.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 10th, 2007 by Dr. Val Jones in True Stories
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I was having lunch in a DC garden hideaway with some colleagues from Revolution Health when the subject of 9/11 came up. We all agreed that it was one of those events that everyone remembers vividly, no matter where they were in the world at the time. Each of us took turns telling the others where we were and what we were doing on that fateful day. Each person’s account was moving and personal. My story follows… [insert fuzzy dream sequence graphics here]
I was getting off a night shift rotation at a hospital in lower Manhattan, sitting in morning report – my eye lids sticking to dry corneas, my head feeling vaguely gummy, thoughts cluttered with worries about
whether or not the incoming shift of residents would remember to perform all the tasks I’d listed for them at sign out.
And as I dozed off, suddenly our chief resident marched up to the front of the room, brushing aside the trembling intern who was presenting a case at the podium at the front of the dingy room. “How rude of him” I thought hazily, as I shifted in my seat to hear what he had to say.
“Guys, there’s been a big accident. An airplane just crashed into the World Trade Center.”
Of all the things he could have said, that was the last thing I was expecting. I shook my head, wondering if I was awake or asleep.
“We don’t know how many casualties to expect, but it could be hundreds. You need to get ready, and ALL of you report back to the ER in 30 minutes.”
I thought to myself, “surely some misguided small aircraft pilot fell asleep at the controls, and this is just an exaggeration.” But worried and exhausted, I went back to my hospital-subsidized studio apartment and turned on the TV as I searched for a fresh pair of scrubs. All the channels were showing the north tower on
fire, and as I was listening to the news commentary and watching the flames, whammo, the second plane hit the south tower. I stared in disbelief as the “accident” turned into something intentional. I remembered having dinner at Windows on the World the week before. I knew what it must have looked like inside the buildings.
I was in shock as I hurried back to the hospital, trying to think of where we kept all our supplies, what sort of injuries I’d be seeing, if there was anything I could stuff in my pockets that could help…
I joined a gathering crowd of white coats at the hospital entrance. There was a nervous energy, without a particular plan. We thought maybe that ambulances filled with casualties were going to show up any second.
The chief told me, “Get everybody you can out of the hospital – anyone who’s well enough for discharge home needs to leave. Go prepare beds for the incoming.”
So I went back to my floor, recalling the patients who were lingering mostly because of social dispo issues, and I quickly explained the situation – that we needed their beds and that I was sorry but they had to leave. They were actually very understanding, made calls to friends and family, and packed their bags to go.
And hours passed without a single ambulance turning up with injuries. I could smell burning plastic in the air, and a cloud of soot was hanging over the buildings to the south of us. We eventually left the ER and sat down in the chairs surrounding a TV in the room where we had gathered for morning report. We watched the plane hit the Pentagon, the crash in Pennsylvania… I thought it was the beginning of World War 3.
The silence on the streets of New York was deafening. Huddling inside buildings, people were calling one another via cell phone to see if they were ok. My friend Cindy called me to say that she had received a call from her close friend who was working as a manager at Windows on the World. There was a big executive brunch scheduled that morning. Cindy used to be a manager there too… the woman’s last words were, “the ceiling has just collapsed, what’s the emergency evacuation route? I can’t see in here… please help…”
That night as I reported for my shift in the cardiac ICU, I was informed by the nursing staff that there were no patients to care for, the few that were there yesterday were either discharged or moved to the MICU. They were shutting down the CICU for the night. I wasn’t sure what to do… so I went back to my apartment and baked chocolate chip cookies and brought in a warm, gooey plate of them for the nurses. We ate them together quietly considering the craziness of our circumstance.
“Dr. Jones, you look like crap” one of them said to me affectionately. “Why don’t you go home and get some rest. We’ll page you if there’s an admission.”
So I went home, crawled into my bed with scrubs on, and slept through the entire night without a page. The disaster had only 2 outcomes – people were either dead, or alive and unharmed – with almost nothing in between. All we docs could do was mourn… or bake cookies.
What were you doing on 9/11? Join our forum to share your stories.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 30th, 2007 by Dr. Val Jones in Health Policy, Opinion
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Labor Day was founded in the late 1800’s as a way to thank
American workers (as Peter J. McGuire, a cofounder of the American Federation
of Labor put it): “who from rude nature have delved and carved all the grandeur
we behold.” There is some debate
about who originated the concept of the holiday, but one truth remains:
“All other
holidays are in a more or less degree connected with conflicts and battles of
man’s prowess over man, of strife and discord for greed and power, of glories
achieved by one nation over another. Labor Day…is devoted to no man, living
or dead, to no sect, race, or nation… It
constitutes a yearly national tribute to the contributions workers have made to
the strength, prosperity, and well-being of our country.”
Resident physicians are on my mind with Labor Day
approaching. I know that they are toiling away in hospitals across the nation,
and many of them do not get to take Labor Day off for vacation. Physicians work for 3-7 years after
graduating from medical school, and are paid (on average) about the equivalent
of a home health aide or a medical secretary but work about twice the hours
during residency. In fact, if you calculate
out the salary by the hours they work, resident physicians are paid about $9
-$10/hour which is roughly $1.50 more than minimum wage.
Not surprisingly, resident physicians have joined unions to
lobby for more reasonable wages and caps on the number of hours they must work
per week. The national cap is now at 80
hours per week – about 20 hours more than a truck driver is allowed to work
(for “safety reasons”). Research from Harvard
suggests that errors made by overworked residents increase by 700% when they
have worked more than 24 hours in a row.
Residents from the University of New Mexico, for example, received wages in the lowest 1% for resident physicians in their region, and
were denied a salary increase until they recently joined forces with CIR (the Committee of Interns and Residents) to
negotiate more reasonable salaries and working conditions. The New
Mexico contract adds one more CIR chapter to the more
than 70 hospitals — each with multiple residency programs — that are part of
CIR.
Founded in 1957 to improve patient care and resident working
conditions, CIR has remained true to those two goals throughout the decades. In
1975, CIR won an end to every other night on-call in New
York City, and created the first-ever Patient Care Fund in Los Angeles, where
residents could purchase equipment or create innovative programs to help
patients. Campaigns to prevent needle stick accidents by moving to safer needles,
or needle-less equipment, have also improved working conditions for residents.
CIR has been on the forefront of safe and humane work hours
for residents, helping to win the 80 hour regulations in New York State
in 1989, which became the foundation for the 2003 national guidelines. But
evidence shows that this is still too many hours, and so the advocacy around
hours continues unabated.
So please have safe travels on your Labor Day weekend – we
wouldn’t want you to wind up at a hospital where the residents work more than
24 hours in a row for ~$9/hour. Resident
physicians are one group of laborers who don’t have much to celebrate yet this
Labor Day. But with CIR’s help, next
year might be a little brighter.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 28th, 2007 by Dr. Val Jones in Health Tips, Medblogger Shout Outs
1 Comment »
I was a bit tired today, thinking about how nice the long weekend will be. A colleague wrote me an email reminder to slow down… he said, “go home and have a nice glass of wine and relax.” I guess research supports drinking in moderation – it’s good for the heart, right?
But then, I noticed this poem in Paul Levy’s blog – and I realized that we docs could all use a little slowing down…
ENCOUNTER ON THE STAIRS
By Warner V. Slack, MD
Next to Children’s Hospital, in a hurry
Down the stairs, two at a time
Slowed down by a family, moving slowly
Blocking the stairway, I’m in a hurry
I stop, annoyed, I’m in a hurry
Seeing me, they move to the side
A woman says softly, “sorry” in Spanish
I look down in passing, there’s a little boy
Unsteady in gait, holding onto an arm
Head shaved, stitches in scalp
Patch over eye, thin and pale
He catches my eye and gives me a smile
My walk is slower for the rest of the dayThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 26th, 2007 by Dr. Val Jones in Opinion
5 Comments »
The Wall Street Journal’s Health Blog recently featured a heated
debate about the utility of online physician ratings. On the one hand, some physicians are worried
that their reputations will be harmed by poor ratings given by a select minority
of disgruntled patients. Some have gone
so far as to ask that their patients sign an agreement not to participate in
online physician ratings. On the other
hand, many physicians view online ratings as a welcome form of constructive feedback
– believing that the ratings will further showcase their already good work.
I believe that physician ratings are not a perfect measure of
quality care, but they can offer a legitimate and enlightening patient
perspective on bedside manner, office efficiency, and communication skills. Many patients have nothing more than a health
insurance company’s list of “in network professionals” from which to choose a
provider. Online physician ratings sites
now give them a little bit more information to guide their selection process.
The potential for inappropriate or libelous postings depends
upon how carefully the ratings company reviews the comments. Open message boards may degenerate into gripe
sessions, but closely monitored ratings like those at Revolution Health, are much less risky. Even more valuable will
be the fusion of consumer ratings, peer reviews, hospital, and health
plan ratings of an individual physician all in one place. This kind of rating system is not far off.
The bottom line is that online physician ratings are here to
stay – and the best way for the ratings to fairly reflect the average patient’s
experience is to have physicians encourage all their patients to rate them
online. In that way, the rare
disgruntled patient’s review will be seen in the context of the majority of
satisfied customers. If the majority of
comments are still cautionary, then it becomes more likely that the physician
him or herself has some work to do.
Since the American Board of Medical Specialties is now
recommending demonstration of patient satisfaction as part of the recertification
process for many specialties, online physician rating sites may actually become
a great (and cost effective) way for physicians to collect such qualitative
data. So my advice to physicians is to
embrace physician ratings and make them work for you and for the benefit of
your future patients. Give the audience
some credit – they won’t judge you on one outlier comment… unless perhaps that’s
the only comment they see.
Your views and dissenting opinions are welcome.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
