July 9th, 2007 by Dr. Val Jones in Opinion
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One of my colleagues just forwarded me a NY Times article by Jerome Groopman. The article begins with the issue of inexperienced interns – how newly minted MDs begin clinical care for patients in July of each year, and how these rookies can make harmful mistakes.
He goes on to explain that doctors aren’t trained to think well about the diagnostic process (the thesis of his recent book) and that we’d all benefit from studying cognitive psychology.
Dr. Groopman makes some interesting points in this article, but I was most struck by his flippancy regarding the dangers of getting treatment in July. He simply says, “Today, most hospitals closely watch over interns.”
I personally think the issue is more sinister than that – 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 24th, 2007 by Dr. Val Jones in True Stories
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During my residency I kept a diary as a way to relieve some of the sadness related to the death and dying that I witnessed. I recorded various encounters in a series of vignettes. Although these are a bit long for a blog, I thought I’d share a few now and then in the hope that they’d preserve the memory of those who are gone. All personal data have been removed so that the identity of the patients is protected.
***
It’s 3:00am and I was paged to examine yet another patient who had fallen out of bed – to rule out a hip fracture.
Too tired to read the chart prior to examining the patient,
I thought I’d leap right into the physical exam. I assumed that the patient would be the usual
elderly woman who, in her sickened delirium, thought she was at home and tried
to walk by herself to the bathroom and fell en route.
I marched into the room and stopped at bed 23. All my pre-conceived notions evaporated as I
looked at the young man before me.
Emaciated and stiff, with all four limbs contracted, he lay on the bed,
clinging to a thin white sheet. The
whites of his eyes flashed in the darkness.
“Hi there.” I said, trying to seem casual at the sight of
the living corpse before me. “I’m Dr. Jones. I heard that you fell. Are you in any pain?”
His eyes suddenly fixed themselves on me and he spoke, not
with a thin raspy voice, but with the robust youthful voice appropriate to his
age rather than the decrepitude of his body.
“I’m in no pain,” he said.
“I was trying to sit down on the chair.
I thought it was against the wall, but it was actually a couple of feet
away. So when I leaned on it, it slid
and I fell on the floor.”
“Do you think you broke anything?” I asked, trusting in his
judgment as his mental status was clearly in tact.
“No, I just scraped my butt,” he said, pointing a frail
finger towards his sacrum.
“Did you hit the floor hard?” I asked as I used my pen-light
to examine his back side.
“Not really,” he said.
“Would you like me to order an X-ray of your pelvis to see
if you broke anything?”
“I don’t think I need it,” he said.
“Well let me see if it hurts when I rotate your leg in your
hip socket, ok?” I pulled down the sheet
and asked the young man to allow his right leg to fall to the side. As I looked down at his hip I gasped slightly
as his inner thigh came into view. A
gaping ulcer lay before me, deep to the bone, exposing tendons and ligaments
with pus, and red knobs of flesh surrounding a football sized hole in the man’s
groin. His paper-thin scrotum lay stuck
to his left thigh. The smell overcame
me, it was at once wet and fetid, with a hint of chemical odor from the
antibiotic ointment that was clinging ineffectively to the fringes of the wound.
“Oh my God. Does that
hurt?” I stammered.
“No, not at all.”
“And does it hurt when I rotate your leg in your hip
socket?” I asked, trying desperately to remain focused on the task at hand.
“No, it doesn’t.”
“Well, then,” I said, gathering my faculties. “I don’t think you broke your hip. And if you don’t want an X-ray, I don’t think
we need one. Perhaps you’d like to go
back to sleep and get some rest?”
“Yes, that sounds good,” he said, drifting off into a
morphine induced altered state of awareness.
I wandered out towards the nursing station, looking around
vaguely for the patient’s chart to make note of my “fall assessment.”
One of the nurses anticipated my need and handed me the
thick plastic folder.
“What does this patient have?” I asked.
“Oh, he has AIDS and metastatic anal cancer” she said as she collected some sputum in a clear plastic cup. “He’s 38 years old.”
“The same age as my boyfriend,” I thought to myself. “And why exactly did he fall?” I asked the
nurse.
“I was trying to help him to get to the commode,” she said printing something on a label. “He fell because I wasn’t strong enough to
hold him up. My right arm is a little
bit weak.”
“And why is your arm weak?” I asked, assuming that it was
because of a small strain injury.
“I have breast cancer,” she said, finally making eye contact
with me.
“Oh my God, I’m so sorry,” I said, feeling the weight of her
diagnosis amidst a ward of terminal cancer patients.
“Well, you know the funny thing is that my husband is
particularly upset. He doesn’t want me
to have a radical mastectomy. He says
that it would hurt to see my body differently than he’s used to… he likes to
think I’m still the bouncy cheerleader I was when we first met. To see me with only one breast is upsetting
to him. And quite frankly, I’m afraid he
won’t be attracted to me anymore. That’s
what scares me the most,” she said, becoming misty-eyed.
My pager let out a familiar series of beeps.
“I’m so sorry,” I said, squeezing the nurse’s shoulder. I paused and tried to be encouraging: “Well, even if you need a mastectomy – I’ve seen some great reconstructive surgeries
where the breast can be reformed at the same time with an implant. Maybe you’ll be a good candidate for that
surgery? I’m so sorry that I have to
run… can we talk later?”
“Sure,” she said, smiling faintly.
***
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 15th, 2007 by Dr. Val Jones in Announcements, Expert Interviews
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I was recently interviewed about my blog (and this week’s edition of Grand Rounds) by Dr. Nick Genes at Medscape. For the curious among you – here is the full Medscape interview with Nick Genes (prior to editing). It gives you a little more information about Revolution Health…
1. You’ve
been involved in writing since medical school, for various audiences. Who are
you trying to reach with your new blog, and how have you found blogging to be
different than the other media you’ve worked in?
The best part about
blogging is that it’s a dialogue rather than a monologue. I find the interactive discussions and
heartfelt responses to be touching and engaging. My previous writing was more academic because
of the medium (medical journals) but now I’ve found that blogging is where I
can really be myself – there is no team of reviewers to scrub my words. So what you read is what you get!
2. I’m
very curious about Revolution Health, your role as Senior Medical Director, and
where you think this is all going. But all revolutions have their origins
somewhere, and yours seems to start… on a yogurt farm. Please share a little
of what that was like, and maybe what early influences have given you such an
interesting background. From small towns to New York City, from theology to medicine, it
seems like you’re living a very rich life.
Yes, I guess you could
say that my origins as a revolutionary are firmly rooted in dairy farming. Although it may not be immediately apparent
how the two are related, Internet startups and cattle herding have their similarities. First, you have to wear many hats – there is
no job too small or too large. If the
cows need milking, and the electric machines are broken, you do it by hand. If a cow breaks through the fence and wanders
off into town, you lure her back with short feed. If a large batch of yogurt curdles, you’ve
got yourself a gourmet meal for your pigs… you get the drift. In a large start up, all manner of unexpected
events happen – but the trick is to handle them quickly and efficiently, and
make sure the outcome is a win-win.
As far as my other
life detours… I guess you can say that I’ve been a victim of my own
curiosity. There are so many interesting
things going on, I just can’t help but want to try them out. In the past I’ve held jobs in the following
capacities:
A protestant minister,
NYC bartender, bank spy, food critic, doctor, cartoonist, computer sales
associate, yogurt mogul, nanny, motivational speaker, biophysics researcher,
graphic designer and revolutionary medical director.
So my life has
certainly been an adventure!
3. How did you get involved with this company? Did Steve
Case find you, or know you from before — or was there an application process?
Is the mingling of medical and computer technology folks going smoothly? Is it a
mix of hospital culture vs. laid-back internet start-up culture? (Foosball and
mountain bikes, or suits and meetings?) Can you make comparisons to your time
with MedGenMed?
A friend of mine had
interviewed at Revolution Health for an executive position and thought that the
company would be a great fit for me.
When I heard who was involved (including Colin Powell, Steve Case, Carly
Fiorina) and that the goal was to create a website to help patients navigate the health care
system, I thought – gee, this sounds serious, challenging and worthwhile. So I sent in my resume, got offered an
interview, put on a bright red suit and announced that I’d heard that there was
a revolution afoot and wondered where I could sign up. They hired me that same day (May 8, 2006) and
it’s been the most exciting job I’ve had to date!
About the “mingling”-
a very interesting question. There is a
hint of Foosball/mountain bike in the mix, but I think we’re a little more hard
driving than that. Since Revolution
Health is in its start up phase, there is simply too much work to do for people
to be playing Foosball. When I started,
there were 30 employees, now there are closer to 300. We are all working long hours on cutting edge
projects that I believe will make a big difference in supporting the
physician-patient relationship, streamlining the process of healthcare delivery
and improving accessibility to the uninsured and underinsured. Revolution has attracted some of the
brightest minds in the tech industry – and they are building products I could
never have dreamed of on my own. Since I have such an unusual background,
I’m bilingual in both techie speak and
physician speak, and this helps a great deal.
Because I understand what physicians and patients need, and can translate
that for the “creatives” we can build some really meaningful tools and products
together.
My time at MedGenMed
was wonderful, primarily because Dr. George Lundberg is a dear friend and
mentor. He has done fantastic work
creating a pure platform (no pharma influence or fees for readers or authors)
for open-access publishing. He taught me
to speak my mind, follow my gut and never compromise my ethics. His book, “Severed Trust” galvanized me into
action – to do my part to improve the damaged physician-patient relationship
that is at the core of our broken system (caused by middle men, volume
pressures and decreased time with patients).
After reading his book, I wanted to do something big – so I joined a
revolution.
3. Revolution
Health has some bold ideas about improving care for its members — getting
appointments with specialists, patient advocacy in dealing with insurance, and
of course, sharing information. What’s your job entail, as medical
director? Do you think you’ll find yourself making policy decisions that
could affect, directly or indirectly, chunks of the population? Could
you find yourself in a position where some specialists are not recommended
based on their insurance? Will Revolution Health have a formulary, will it
be evidence-based — or could could care be rationed ?
My job is incredibly
challenging and fun, and I rely on both halves of my brain for much of what I
do. We have 146 medical experts most of
whom I’ve personally recruited, I’m responsible for coordinating the medical
review of all the content on our portal (so that it conforms with
evidence-based standards), I facilitate relationships with major hospital
systems (such as Columbia University Medical Center), spearhead new product
initiatives (such as Health Pages for physicians), monitor and promote our 30+
expert bloggers, participate in writing press releases, creating podcasts, radio interviews,
identifying new partnership opportunities and much more.
I do think that
Revolution Health will greatly influence vast “chunks” of the population. And this is what’s particularly exciting
about working here. We really are
building a brand new navigational system for healthcare – and this will empower
patients to take control of their health and provide them with better
information and guidance in living their best.
I believe that Revolution Health will become the new virtual medical
home for physicians and patients, just the way that AOL grew to be America’s
Internet home. You log on first to AOL
to get your email, check your news, and get plugged in before surfing the
net. You’ll log in to Revolution Health
to track your health, connect with your lifestyle coach or physician guide, get
involved with a community of others like you, or track your loved ones’ health
issues through Care Pages. This is a 20
year project, so all of our plans and programming may not be apparent yet, but
the trajectory is amazing and I wouldn’t want to be anywhere else as a
physician today.
5. What are some of your favorite posts — something that
struck a nerve with readers, or captured something you wanted to express?
Please provide links!
My absolute favorite
post is the story of how my mom, a strong patient advocate, saved my life as a
baby. She refused to accept the
misdiagnosis I was given, and continued to nag the medical team until they
realized what was wrong and took me to the O.R.
If it hadn’t been for her persistence (or the incredible skill of the
surgeon who ultimately took care of me), I wouldn’t be here today. And maybe that’s why I’m passionate about
both good medical care AND patient empowerment!
Other posts that have
been well received are true stories from my medical training days. Some are controversial (like this one about
end of life issues and my first day as a doctor),
and others are warmer reflections. But ultimately, I just share what’s on my
heart and let the audience take away what they can from it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 11th, 2007 by Dr. Val Jones in Announcements
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Not sure how many of you are aware of this touring
anatomical science exhibit – but it’s been making its rounds through major cities in the U.S. and Europe. I finally went to see it this weekend in DC, and it was both amazing and slightly disappointing.
It was amazing because of the meticulous dissection work done by the Chinese scientists. It was disappointing because, after months of viewing the awe-inspiring marketing photos of colorful cadavers playing soccer, football, conducting an orchestra, etc. I had some sort of unconscious expectation that there would be movement in the exhibit, or at least some medical animations and multi-media. Instead, the exhibit was flat – nothing moved, no multi-media, and much of it was comprised of cadaver slices and organ sections. The attractive, eye catching cadavers made up a very small portion of the exhibit.
Now, I wondered how these cadavers could be unscented (I was told beforehand that there was no odor problem – the way there was in anatomy lab in medical school), and as it turns out it’s because they are not cadavers at all. No, the Bodies are actually plasticized fossils. So the reason they don’t smell is the reason why dinosaur “bones” don’t smell – there are no bits of tissue left.
All that being said – I really have to tell you that seeing these meticulously dissected fossils made me realize how useless medical school anatomy lab really is. A surgeon once told me that he found anatomy lab “a total waste of time” since the anatomy of living flesh bears little resemblance to the greasy beef jerky (sorry to be so graphic – but it’s true) we poke through for months on end at medical school. These Bodies were incredibly beautiful – and I truly saw (and understood) for the first time the exact relationship of every nerve, muscle, tendon, artery and vein to the greater picture. How I wished I could take one of the bodies home with me to study it! Netter is great – but there’s nothing like 3-D to really understand the relationships.
So I can only hope that medical schools will seriously consider offering courses conducted on these beautifully dissected fossils, rather than the smelly, obese cadavers that we muck through today (no disrespect meant to the donors – they are kind to offer their bodies to science). Anatomy is critically important in medicine – but I’m not convinced that the current educational system is set up for maximum impact. Skip anatomy lab – spend some time at the Bodies Exhibit.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 26th, 2007 by Dr. Val Jones in True Stories
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Even though the gender gap in medicine is closing quickly (about 50% of medical students are female), young female physicians in practice are often viewed with suspicion. Dr. Michelle Au, an anesthesiologist and graduate of my alma mater, is regularly asked if she’s “a real doctor” or if she’s the nurse or a student of some sort. This week she blogged about her experiences, and there was a large volume of interesting responses.
I myself have had a rough time of it in the past (now I guess I look old enough to “be a real doctor”), and was routinely assumed to be a nurse, physical therapist, or even pharmaceutical rep. I actually wasn’t that offended by being miscast – mostly because I took it as a compliment not to look like a doctor. Although it’s somewhat unclear what a real doctor is supposed to look like, I have a feeling he’s older, balding, and paunchy.
But one day I was a little annoyed when my age and gender was equated with incompetence, which crosses the line for me. Here’s how the conversation went between me and the parents of a toddler with a small cut on his forehead:
Me: “Hi, Mr. and Mrs. X, I’m Dr. Jones. I see that Johnny bumped his head and will need a few stitches.” [Enter long history and physical discussion here].
Mrs. X: “Are YOU going to put in the stitches?” She asked nervously, scanning the ED for other physician suturing candidates.
Me: “Yes, I assure you I will be very careful. I’ve sutured many similar lacerations.”
Mr. X: “Yeah, but don’t you think he needs a plastic surgeon?”
Me: Looking at the small cut that only required 2 or 3 sutures. “I understand that you want the best possible cosmetic outcome for your son, but I assure you that this cut is so small that the plastic surgeon wouldn’t close it any differently than I would.”
Mrs. X: Spotting a tall, male intern fiddling with some bandages on a supply cart. “Well, can’t he do it?”
Me: Viewing the clumsy medicine intern. “Well, yes, he could. Shall I ask Dr. Big Hands if he can come and suture your son’s forehead? He’s never closed a lac before and has been dying to try one.”
Mrs. X: Um… Well, maybe you should just do it.
Outcome: I did a beautiful, delicate job of closing the small laceration, and the parents watched in awe as I used the tiniest needle and thread to create a seamless finish.
Mr. X: Thanks for your help. You did a really great job.
Have any of you readers had similar experiences?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
