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The Downfalls Of Medical Care In America’s Rural Communities

Malinda Bell I graduated from medical school in 1985, am board certified in EM and practiced 25 years—mainly inner city/trauma/teaching centers. However, the last 5 years were in a rural 25-bed hospital, 60 miles from a shopping mall or hospital with higher capabilities and specialists. My hourly rate was competitive and the hospital provided benefits included: malpractice, health, dental, & vision insurance, prescription coverage, paid vacation/CME allowance, and pension contribution.

Palliative Medicine (intensive symptom management for chronic or serious illness, coordination of care and clarification of patient/family treatment & life goals) is a subspecialty in urban settings but is lacking and most needed in the rural community setting. The chronically ill patient who is also typically elderly may present to the ED and be denied hospital admission after an ED physician evaluation. The doctor can “request” admission from an at-home Utilization Review nurse who checks the admission guidelines and if not met, reports the patient is to be sent home—even if it is over the objections of the physician who has evaluated the patient. There is no systematic follow-up of these patients, and they are told to “contact your primary care physician.” No one is making sure this happens. Some do not have primary care physicians and may be unable to obtain a timely appointment. The hospital does not have a social worker to coordinate care or provide assistance in the confusing navigation of insurance/appointments/outpatient testing, etc. There is no 24-hour pharmacy. Many of these patients do not have transportation or no longer drive and often live many, many miles from the hospital relying on neighbors, church folk, or county ambulance when they become ill.

In 2010, I opened Read more »

More Medical Waste: Does A $6000 Flashlight Improve Patient Outcomes?

So I’m rounding in the ICU the other day when I came upon this new hospital medical device.  It’s called a pupillometer.  What does this pupillometer do?  It  measures subtle changes in the light reflex of the pupil to help take the physical exam to the next level of precision.

Or eliminate it, depending on how you look at it.  What used to be a basic physical exam skill is now being replaced by a $6000 piece of medical technology that can distinguish tiny changes in pupil size. Now the real questions remain.  Has this pupillometer device gone through the rigors of randomized trials in the ICU to define whether a  $6000 flashlight changes outcomes or mortality?   And if not, how do we allow medications to require such testing but not the technology that often changes nothing and simply makes health care more expensive.

The way I see things, if I’m trying to decide whether someone’s pupils constrict 1% vs 3% vs 10%, I’m getting a palliative care consult instead and putting the pupillometer back in my holster.

First the vein light.  Now the pupillomter.   And I thought the super bright LED pen light was all the rage.

*This blog post was originally published at The Happy Hospitalist*

Hospice Patients Spend Less Overall Time In Hospital But More Days In The ICU

Chronically-ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003, but their intensity of care increased as well, according to a report by the Dartmouth Atlas Project.

While in the hospital less, patients had many more visits from physicians, particularly specialists, and spent more days in intensive care units, as result of growth in intensive care and specialist capacity, the researchers said.

Intensive interventions can lower a patients’ quality of life and cost more, the researchers noted. About one-fourth of all Medicare spending stems from the last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease, the authors noted. Following patient preferences for end-of-life care may reduce such spending. Read more »

*This blog post was originally published at ACP Hospitalist*

Emergency-Palliative Care: “We Can’t Save You”

An alert reader alerted me to this related piece in Slate: “We Can’t Save You: How To Tell Emergency Room Patients That They’re Dying.” An excerpt:

The ER is not an easy place to come to these realizations or assess their consequences. A handful of physicians are trying to change that. Doctors like Tammie Quest, board-certified in both palliative and emergency medicine, hope to bring the deliberative goal-setting, symptom-controlling ethos of palliative care into the adrenaline-charged, “tube ’em and move ’em” ER. Palliative/emergency medicine collaboration remains rare, but it’s growing as both fields seek to create a more “patient-centered” approach to emergency care for the seriously ill or the dying, to improve symptom management, enhance family support, and ensure that the patient understands the likely outcomes once they get on that high-tech conveyor belt of 21st-century emergency medicine.

Emergency medicine and palliative care-certified? That’s an interesting mix. We have a great palliative care service where I work (in fact, it just won the national “Circle of Life” award.) It makes a lot of sense to have a palliative care nurse stationed in (or routinely rounding) the ER, though. I think I’m going to suggest this to our hospice folks.

*This blog post was originally published at Movin' Meat*

Another Reason Why Doctors Don’t Discuss End Of Life Care

A recent study suggests that doctors may put off holding end of life care discussions that involve subjects like advance directives, hospice or site of death.

Recommendations suggest that physicians hold these conversations when patients have about a year to live, but the data show  those guidelines aren’t being followed.

Why? Read more »

*This blog post was originally published at KevinMD.com*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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