Archive for the ‘Policy’ Category

14 Ways To Know Whether You Are Failing As A Hospital Administrator

Sunday, July 5th, 2015


I’ve been an administrator.

I’ve seen hospitals in which a strong leadership team has improved the hospital’s market share and I’ve seen hospitals that have closed and that are struggling to stay open due to a failed administrative team. Here are some common traits I’ve seen in the failures:

1. You don’t know the names of the people who work in your corporation. You aren’t fooling anyone when you walk the halls without addressing people by their names. All this shows is that you don’t care to take the time to know them. If you don’t take the time to get to know them, why should they care about your corporation?

2. You spend a lot of time and effort seeking feedback about your employees’ performance, but you spend little or no time seeking feedback about your own performance. All this shows is that you are a hypocrite. People hate hypocrites.

3. Your hospital has a high employee turnover rate. This isn’t an issue with employees, it is a clear and unequivocal issue with management. People don’t leave their jobs, they leave their bosses. If your hospital has a high turnover in one department and you aren’t seriously evaluating that department manager’s work, you have no business running a hospital.

4. Your “help wanted” listings go unfilled. In an economy with high unemployment, the fact that people would choose to stay unemployed rather than work for you and your organization is a good reflection of the public opinion about the business you are running.

5. Your employees leave the room when you walk in or they try to avoid you in the hallways. When no one wants to be around you in your workplace, it isn’t a sign of respect, it’s a sign of disgust. Keep that in mind the next time you see someone duck into a stairwell when they see you walking down the hall.

6. You don’t show up at holiday parties for your employees. If you feel uncomfortable mingling with your employees at a party, you shouldn’t be trying to lead them. The good thing is that if you feel uncomfortable attending an employee party, your employees probably won’t want you there, anyway.

7. You don’t participate in charity events for employees or employee family members. Your failure to support your employees in their times of need will only drive everyone to dislike you even more.

8. You don’t support employees who have been injured. Or worse yet, you try to terminate employees who have been injured. News of these types of actions spreads quickly through the hospital. Again, if you don’t have their backs, what makes you think that they’ll have yours?

9. You care more about your bottom line than you care about your patients’ or your employees’ bottom lines. When you create policies to increase your bonuses, you employees will know and they will resent you for it. They may even make passive aggressive attempts to keep you from reaching your goals.

10. You spend more time criticizing your employees than you do complimenting your employees. Worse yet – you don’t compliment your employees at all.

11. You display favoritism. If you allow anyone to drop your name or to use their relationship with you to gain an advantage at work, your employees will quickly grow to resent you and your clique.

12. You discourage constructive criticism of your organization from within. If you think everything is going just fine in your facility, you’re out of touch and you’re wrong.

13. You don’t act on employee concerns. Your failure to follow up on an employee concern not only shows that you’re unreliable, but it also may serve as a basis for legal action if something related to that concern goes wrong.

14. You don’t visit the departments in your hospital on a regular basis. If it’s been more than a week since you’ve visited any department in your hospital, you have lost a great opportunity to compliment your employees on the job that they are doing. You have also lost the ability to uncover and address small problems before they become big problems.

Semantics and the $28 Million Unnecessary Test

Friday, April 10th, 2015

MRI LumbarThere’s been an awful lot of Internet hullabaloo about “unnecessary testing” lately. The Choosing Wisely program keeps trying to assert that we should not perform any “unnecessary” tests. Recently, a paper was published in the Journal Academic Emergency Medicine alleging that “overordering of advanced imaging may be a systemic problem” since many emergency physicians believe that such testing is “medically unnecessary.” The paper was based on surveys that were presented to emergency physicians and the work was at least partially funded by the Veterans Administration and the National Institutes of Health — which should be considered a conflict of interest. After all, don’t the entities that pay for the testing stand to gain to gain the most from limiting “unnecessary” testing?

But now that the paper has been published, the media has been whipped up into a frenzy, stating that doctors admit they perform “unnecessary” testing and are single-handedly bankrupting our medical system.
Consultant Magazine has an article stating that “ordering unnecessary imaging tests ‘may be a systemic problem.’”
NewsMax Health states that “97% of ER docs order unneeded tests out of malpractice fears
HealthLeaders Media trumpets that “97% of ED physicians order unnecessary imaging tests
Even Time Magazine has a headline stating that “your doctor likely orders more tests than you actually need.”
However, I’d bet my white coat that if you asked any of the study authors or any of the authors of the articles in these prestigious magazines what the definition of an “unnecessary test” was and how to prospectively determine whether or not a test is “unnecessary,” they would all look at you with blank stares and shrug their shoulders.

Unfortunately, defining the term “unnecessary” is more difficult than it seems. The American Heritage Dictionary defines “unnecessary” as being “not necessary.” In turn, “necessary” is defined as being “needed or required.” “Needed” is defined as “A condition or situation in which something must be supplied in order for a certain condition to be maintained or a desired state to be achieved.” This definition gives us a little bit of help, but is still vague as it applies to medical care. When discussing advanced medical imaging, a necessary test would be that which must be performed so that a “certain condition can be maintained or a desired state can be achieved.” Ruling in or ruling out a disease process would seem to fit that definition.

Based on the paper’s abstract, it appears that almost 500 emergency physicians were given a survey and 97% of them stated that at least some of the advanced imaging studies (CT scans and MRIs) they personally ordered were “medically unnecessary.” In other words, the researchers took a politically charged statement and, using a fallacy of definition, created a statistic which is in itself both untrustworthy and sensationalistic. Rent-Purchase
The questions used in the survey aren’t available. If you want to look at them, you can “rent” the article for $6 or you can splurge and purchase the article for $38 – neither of which I’m planning to do. However, consider the questions that would be raised if the researchers asked 500 people whether they were “good parents” and then published a study saying that, based upon survey data, bad parenting did not exist in the United States. Or consider a study asking doctors if they acted in “professional manner” and then declaring that unprofessionalism does not exist in medical care because 97% of doctors answered “yes.” Those studies would get laughed out of Medline because it is easier to see the bias in asking people ambiguous questions when the terms of the questions haven’t been defined. That’s why I’m very surprised that some of these authors would put their names behind a paper with such dubious conclusions.

Shortly after the JAEM paper was published, Lenny Bernstein then published an article in the Washington Post noting that patients with low back pain who were first sent for MRIs instead of first going to physical therapy paid an average of almost $5000 more for their medical care. The reason was apparently that MRIs tended to show all kinds of “benign changes” in the patient’s backs. The article is based on a study in the Journal “Hospital Services Research.” Again, it will cost you $6 to rent or $38 to own this piece of research. It would be nice to know whether or not the authors, two of whom were physical therapists and one of whom was a researcher in “Clinical Quality and Outcomes Research”, discussed whether there were any adverse outcomes associated with proceeding directly to physical therapy as opposed to obtaining advanced imaging. It is difficult to draw any conclusions from the abstract other than physical therapists are advocating more physical therapy for low back pain.

Finally, also published right around the same time as the above two articles, there was an article in the Los Angeles times noting how Kaiser Permanente was ordered to pay a young woman more than $28 million after delaying an MRI that could have detected an aggressive cancerous tumor. According to the article, the patient was 17 years old and experiencing severe lower back pain. She and her mother repeatedly requested an MRI of her lower back, but the patient was instead told that, at 125 pounds, she had too much “belly fat” and needed to lose weight. After three months, Kaiser ordered the MRI and found a large fast-growing cancer in her pelvis. Ultimately, the patient required amputation of her right leg, removal of half her pelvis and part of her lower spine in order to remove the tumor. The patient’s lawyer argued that her leg and pelvis could have been saved had the MRI been performed and the cancer diagnosed earlier. Kaiser argued that the cancer was already so large that the patient would have lost her leg even if they had ordered the MRI sooner.

Admittedly, it is difficult to determine whether care was appropriate based upon an incomplete clinical picture, but I think we can safely assume that the patient falls into the “don’t image” guidelines that ACEP has created for the “Choosing Wisely” initiative (see guideline #8).
Note that the Choosing Wisely guidelines for acute low back pain are different than the low back pain “red flags” that are traditionally considered an indication for diagnostic imaging. This patient had at least two “red flag” symptoms.

The Kaiser case also raises an issue as to whether or not the jury award was unreasonable and based upon emotion rather than based upon the patient’s injuries. However, consider that the award must provide for lifelong care of a young adult who had to have her leg amputated, half of her pelvis removed, and part of her spine removed. She’s going to require quite a bit of care and is going to go through a lot of suffering for the rest of her life. This case took place in California where there are caps on the “suffering” or “non-economic” portion of the damages. We don’t know how much of the award was based on future medical care and punitive damages (neither of which are subject to the caps) versus noneconomic damages which would be capped at $250,000. If the patient was able to introduce evidence that Kaiser had a pattern of engaging in denial of care to increase profits as the article suggests, punitive damages would be more likely to be imposed.

The thing I found most interesting about the Kaiser case was that Kaiser did not argue that the MRI of the young patient’s lumbar spine was an “unnecessary” test. Nobody in the comment section of the article argued that the MRI was an “unnecessary” test, either. Why? Because the results of the test were positive and anyone who argues that a test is “unnecessary” when it shows gross abnormalities needing immediate therapy would be viewed as an idiot. Had the exact same MRI in the Kaiser case been normal, everyone would have rolled their eyes, shook their heads, and proclaimed what a waste of money it was to perform the test. However, because the MRI was grossly abnormal, the consensus is instead that the test was not only “necessary”, but that it should have been performed much sooner.

This concept underscores why the JAEM article is so misleading. The authors don’t adequately define the terms on the surveys that they provided and, as a result, the conclusion they base on those ill-defined terms do not pass scrutiny. When we define the utility of a test by that test’s results, we engage in medical mumbo-jumbo which neither improves the health of patients nor improves the practice of medicine.

It sure makes for some great “unnecessary” headlines, though, doesn’t it?

How To Discourage A Doctor

Friday, September 26th, 2014


This post should be required reading for every physician in this country.

A physician finds a document on a chair in his hospital executive’s waiting room and reads through it, then realizes it is a manifesto on how to disempower physicians and put hospital administrators in control of patient care. The document’s title: How to Discourage A Doctor

While the physician implies that he transcribed the information from memory, the formatting breaks and text errors in the document make it appear as if the document was scanned and then the text pasted.

Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures”
Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness”.
“Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control.”

Whether the entire backstory of the article is true or more of a parable, the concepts described are being implemented … and they are a serious threat to the health care in this country.

Look at some recent medical research.

This survey showed that hospital ownership of private physician practices has increased dramatically in the past 6 years. In 2008, 62% of physicians owned private practices. This year, only 35% of physicians maintain independent private practices. Only 9% of physicians “mostly agreed” that hospital employment of physicians would increase quality of care and decrease costs. 81% of physicians described themselves as “overextended” or at full capacity.

This survey showed that government regulations regarding electronic medical records are being implemented but that 75% of physicians believe that the electronic medical records increase costs and do not save time. 68% of physicians do not believe that the regulations improve productivity and 48% do not belive that the regulations support coordination of medical care.

This study showed that time lost in dealing with electronic medical records was “large and pervasive”, costing physicians an average of 48 extra minutes a day – during which they could have been performing other tasks such as patient care.

I’m sure that hospitals, their administrators, and their attorneys will all deny that they are trying to discourage physicians or to drive a wedge between physicians and their patients. Draw your own conclusions.

However, as more physicians move to hospital based practices and exhibit less autonomy, think about who stands to gain and who stands to lose from such transitions.

Assistant Physicians Coming to Missouri

Sunday, June 22nd, 2014

Lucy VanPelt The Doctor is INMissouri is planning to allow medical school graduates who have not completed residency to treat patients in underserved parts of the state. Bills that would allow medical school graduates to provide medical care have passed the General Assembly and are awaiting Governor Jay Nixon’s signature. The newly-minted physicians would receive “assistant physician” licenses and would be able to treat patients in collaboration with a licensed physician – much in the way a physician assistant does. However, the new graduates will be able to call themselves “doctor” while physician assistants will not.
Now the American Academy of Physician Assistants is up in arms because the arrangement would “jeopardize (physician assistant) practice” and because these insufficiently trained Assistant Physicians might be confused with Physician Assistants. The new doctors will have more schooling than the physician assistants, but will only be required to work with a collaborating physician for one month before they can practice alone.
One other important thing to note in the legislation: The collaborating physician maintains full responsibility for all actions of the assistant physician. In other words, if the assistant physician commits malpractice, the supervising physician takes the fall for it.

Creative licensing such as this will be a boon to states since each of these extra providers will have to pay significant licensing fees to the states each year.
When the assistant physicians can’t fill the void in access to care, next up will be medical students who independently treat patients in remote campsites and who receive a “Assistant Physician Aide” designation.
When still more providers are needed, Missouri can then license college students who have completed 12 hours of Basic Life Support and who have any scouting merit badges, calling them “Pre Assistant Physician Aides.”

Anyone should be able to provide medical care. Parents already do it to their children. Just like people who choose to purchase a Kia rather than a Mercedes, people who want to pay five cents for Lucy’s psychiatric treatment versus far more for a formal Dr. Phil evaluation should be allowed to do so.
Two things can’t be overlooked:

  1. The credentials and training of the person providing the care must be fully disclosed to the recipients of the care
  2. Those providing the care must be subject to the same regulations, responsibilities and penalties of any other provider performing the same actions. Providers shouldn’t be able to escape liability for negligent actions by blaming someone else or by alleging that they are behaving reasonably given their amount of training. If you want to do brain surgery, you’re held to the standards of a brain surgeon, not a pre assistant physician aide.

We need to carefully consider the evolving paradigm of medical care in this country. The Affordable Care Act ostensibly provided Americans with medical insuance. Now that the bill comes due, how should Americans be receiving care? See tomorrow’s post on my other blog at DrWhitecoat.com for more discussion of this topic.

UPDATE JUNE 25, 2014

Additional article on the topic here

BMI Measurements Inaccurate But Still A Government Gold Standard

Saturday, June 14th, 2014


Everyone needs to read this NY Times article and then think about how inane the concept has become.

The Body Mass Index or “BMI” is used as a measure of a person’s body weight. If your BMI is between 18.5 and 25, you’re normal. More than 25 and you’re overweight. More than 30 and you’re obese. The measurement is based on a person’s weight and height, but it was originally created in the 1800s to measure human growth – not as a measure of a person’s ideal body weight or health. More recent studies show that people considered “overweight” using the BMI measurement are healthier than those who are at the lower end of the “normal” measurement. One study shows that likelihood of death increases with a BMI of less than 23. BMI doesn’t account for the distribution of body fat (abdominal fat is less healthy), BMI falsely classifies muscular individuals as “obese”, and even the CDC has recommended that doctors not use BMI as a diagnostic tool.
Yet what is one of the things our government requires that doctors calculate on every patient’s chart in order to meet “meaningful use” criteria?
You guessed it.
A BMI measurement.

This is what happens when inmates run the asylum.

The reason that we are being required to measure BMI isn’t because a patient’s BMI has any meaningful clinical use … it’s that the BMI can be measured. If it can be measured, it can be tracked. If it can be tracked, then people (essentially health care providers) can be manipulated and penalized if some arbitrary number on a meaningless scale isn’t reached.

Think about it. If we tried to find other substitutes for “health”, they would be difficult to calculate. How many calories does a patient eat? How much alcohol does a patient drink in a day or week? How much exercise does a patient get each day or week? There’s no standard way to objectively quantify or objectively measure any of those criteria.

Instead the government sticks with something easy to measure – even though it has no bearing on a patient’s health. With a little propaganda, the government can make all the patients who don’t know any better think that BMI really is a useful measure of health. Then, if the BMI isn’t calculated and put on the patient’s chart, it gives the government a means to reduce or deny payments to the healthcare providers.

Calculating a BMI and asserting that it is a representation of health is like measuring the number of clouds in the sky at 3PM each day and claiming that a higher number of clouds is an accurate representation of good government.

The scary thing is that another industry has been making similar assertions for years and certain village idiots just continue to believe the misinformation.

Patient satisfaction scores have long been asserted to be a surrogate measure for healthcare quality. Of course, those assertions are made by corporations which receive hundreds of millions of dollars each year from hospitals so that they can compare one hospital to another … on a statistically invalid and entirely misapplied metric. Studies prove that higher satisfaction is associated with higher healthcare costs and almost double the amount of patient deaths. Recall the story about the Texas neurosurgeon who maimed and killed patients yet who had great Healthgrades.com scores (which were suddenly removed by the Healthgrades staff when the story broke). Healthgrades knows its data are inaccurate, but persists in collecting and disseminating inaccurate and potentially dangerous information.
Junior high statistics classes teach twelve year olds that inadequate sample sizes automatically prevent you from making valid conclusions from the results. Want a real life example? Open up a pack of skittles, take out 5 pieces of candy, note the proportion of colors, and then see if those proportions match the proportions of colors left inside the pack.

Despite the woefully inadequate sample sizes and scientific evidence showing that these measures have no bearing on patient outcomes, the same government that relies upon BMI measurements as a representation of health is going to rely upon patient satisfaction scores as a measure of healthcare quality … and will reimburse hospitals less for care when they have lower satisfaction scores. Hospital administrators and hospital governing boards swallow this obviously inaccurate and misleading information like high school kids sucking beer through a beer bong — all in the name of profits with little regard to the adverse effects on patient health.

It is refreshing to see that hospitals are starting to be held accountable for these decisions. It is easy to prove administrative negligence and hospital board liability when bad faith actions harm patients so that hospitals can earn more money.

After all … the sun is shining. That means that BMI measurements and payment for satisfaction are bad government policies that no one should follow.

I’m a scientist. I know these things.


Thursday, March 27th, 2014


I recently got into a rather … shall we say “colorful” … discussion with another doctor about lawsuits. I’m involved in another one. This one is even more screwy than the one I wrote about before. But this lawsuit isn’t finished yet. I expect that it will be over with in the next few months, but I’ll have to wait and see about that.

The discussion centered around medical records, which were one of the issues in my lawsuit.

The other doctor believed that what people write in the chart plays a big part in whether a doctor is successfully sued. In other words, the doctor believed that medical providers largely have the ability to document themselves out of a lawsuit.

I, on the other hand, asserted that charting generally does more harm than good. Sure, a well documented chart may make a doctor look more thorough and conscientious, but in the end if a diagnosis is missed, experts and jurors will work backwards from the diagnosis to determine all of the things that a doctor should have done to arrive at the diagnosis. If it’s a difficult diagnosis, documentation *may* save you. But if it is a disease where a patient manifested a couple of symptoms – even if those symptoms were nonspecific – documentation won’t do much. Electronic charting also provides a LOT more information, so it gives plaintiff attorneys more opportunity to show inconsistencies within a patient’s complaints, review of systems, and physical examination. Create an inconsistency by checking the wrong box or accidentally clicking “yes” instead of “no” and you look like either a careless schlubb who couldn’t be bothered to do an accurate exam or you look like someone who’s documenting an exam you didn’t perform in order to bill more money.

Then I started thinking. You know where that leads.

Suppose that a patient came to the emergency department with chest pain. He has a couple of risk factors for heart disease. His chest pain wasn’t classic cardiac pain, but he had chest pain. His EKG didn’t show any acute changes, but sometimes they don’t when someone has angina. His blood tests were normal, but again, blood tests often are normal when someone has angina. The pain gets better, so the emergency physician sends the patient home with a diagnosis of “chest pain” and instructs the patient to follow up with his doctor. But the patient doesn’t live that long. He dies that night from a heart attack.

Of course there’s going to be a lawsuit because a patient died from a heart attack after going to the emergency department with chest pain. I’m not going to argue whether or not the physician should have been sued. I didn’t give enough information in this example for anyone to make that determination.

My question is this: Given this scenario, is there anything about the chest pain patient’s history or physical exam that the physician could write in the chart to lessen the likelihood that he would be sued? If you were jurors, what types of things would sway your opinion (if anything) and make you decide that the doctor shouldn’t be liable for missing a heart attack in a patient complaining of chest pain? If the medical professionals were acting as expert witnesses, what documentation (if any) would make it more likely for you to conclude that the doctor complied with the standard of care?

I’ll let you know my thoughts once I read some comments.

CMS One Way Data Transparency

Thursday, January 23rd, 2014

1-23-2014 8-42-19 PMAccording to an article on the CMS Blog, in 60 days the government plans to begin disclosing information regarding payments it has made to individual physicians. In order to receive the information, there has to be a FOIA request and each request will be evaluated on a “case by case basis” which means it is unlikely that they plan to just give their entire payment database over to the first person who makes an inquiry. However, the CMS blog states that the government is planning to publicly disseminate aggregate information regarding payment information.

The AMA, all of the State Medical Societies, and a few dozen specialty societies all oppose the idea (.pdf file), alleging that privacy rights of the physicians would be violated, that releasing raw data would result in “inaccurate and misleading information,” and that releasing information such as a physician’s National Provider Identifier would subject the physicians to identity fraud.
On the other hand, watchdog groups such as the “Council for Affordable Health Coverage” believe that all of the data regarding physician payments should be on a publicly accessible database rather than being disseminated on a case-by-case basis.

CMS responded to the medical establishment’s concerns by stating that before releasing individual data, it will consider the “importance of protecting physicians’ privacy and ensuring the accuracy of any data released as well as appropriate protections to limit potential misuse of the information.”

To me, this should be a no-brainer. If any entity does business with the government – not just physicians – disclosure of what services are being performed and what payments are being made should be a right to every citizen.  Remember that whole bit about establishing a constitution on behalf of “We the People”? Remember Abraham Lincoln’s dream of a government of the people, by the people, and for the people? People are the government. If We the People are paying for services through taxes then there is always an overwhelming public interest in seeing how much We the People are paying. If those providing services to the government don’t like it, then do business somewhere else.

With very few exceptions, We the People should be able to see a full and detailed accounting of all government income and expenditures – not just aggregate physician payments.

That’s where CMS’ whole “we’re disclosing physician payments to prevent fraud and abuse” argument falls apart.

Payments to individual doctors are going to be disclosed. Also, any payments or “transfers of value” physicians receive from pharmaceutical companies or medical device manufacturers is also on a government database.

What isn’t going to be disclosed?

  • It isn’t clear whether CMS will release payments to physicians per individual procedure or per individual office visit. My guess is that it won’t. So you won’t know whether your doctor works 4 hours a day twice a week or 12 hours a day for seven days a week to get the payments that CMS is disclosing. You won’t know the overhead in the doctor’s office or the amount of the payments on the doctor’s student loans or the thousands of dollars each month that the doctor pays in malpractice premiums. CMS won’t tell you to divide their “payment” by at least one third to account for taxes that the doctor pays. CMS will just provide you with a number so that everyone can shake their heads at how unfair it is that medical providers are being paid so much
  • It also isn’t clear whether CMS will break down payments to hospitals by specific ICD-9 or CPT codes. To be fair, CMS has published aggregate data for payments to hospitals for the top 100 DRGs, but those payments are several years out of date, in the aggregate, and only involve “average covered charges” and “average total payments” but do not itemize what CMS pays the hospitals for specific services. The aggregate payments include intangible variables such as “teaching,  disproportionate share, capital, and outlier payments” so it is impossible to compare “apples with apples” using the data.
  • And CMS definitely won’t divulge information about patients. The Federal Register Notice (.pdf file) signed by CMS administrator Marilyn Tavenner and approved by Kathleen Sebelius, the Secretary of the Department of Health and Human Services specifically states that “in all cases, we are committed to protecting the privacy of Medicare beneficiaries.” Those superusers and drug seekers who run up the health care tab on the public dime are protected from scrutiny.

On one hand, CMS alleges that it wants to create transparency to avoid fraud, but on the other hand it releases only select data.

Where is the data on how often CMS has denied payments to physicians or to healthcare organizations for services that were provided?
Where is the data showing why those payments were denied?
Where is the data showing how often the denials were reversed and how much extra time that CMS was able to avoid paying for legitimate services by inappropriately denying payments?
Where is the data on the average length of a phone call it takes to contact CMS regarding an inappropriate denial?
The fact is that we don’t get the “transparency” when we look back at CMS.
It’s a one-way mirror.

If we’re really interested in combating fraud, why can’t we get FOIA requests for aggregate payments made on behalf of patients? We don’t need to know what the payments are for and public agencies delivering social security or welfare benefits are not covered by HIPAA privacy rules, so don’t even go there.
Shouldn’t it be my right to see how much of my tax dollars are being paid to the guy on disability down the road with the souped-up Escalade who goes on vacation more than I do and who is out on the golf course all day? Or is it that fraud only of “public interest” when it is committed by medical providers?

CMS is taking this approach for one reason – to vilify medical providers.

With 37% unemployment in this country, medical providers are an easy target. Publish data that inflame a large proportion of the population, allege that medical providers are being “greedy” for not accepting pay cuts, then use that negative public opinion as a means to justify cutting payments and creating even more laws and regulations that make the practice of medicine even less appealing. When you’ve driven enough providers out of health care so that there isn’t sufficient access to all the aging baby boomers and newly-minted Medicaid patients, you can blame that on the medical providers, too. How dare we not provide care to our fellow citizens.

I’m all for transparency, but there needs to be global transparency, not a bunch of smoke and mirrors labeled as “transparency” and used as a means to an end.
You want to publish the data? Publish all of the data.

Come to think of it, maybe we can create public databases of all the payments and perks to all government officials. How much in “transfer of value” has Kathleen Sebelius received since she entered office? Business trips? Meals? Office supplies? Travel?

Betcha those numbers would put payments provided to most medical providers to shame.

Alarm Fatigue

Wednesday, May 1st, 2013

Alarm Clock (Copy)For those of you who don’t know what alarm fatigue is, think of a car alarm. The first time you hear it going off, you run to your window to see who’s breaking into a car. Maybe you run to the window the second time and the third time, too. By the tenth time the alarm goes off, you’re thinking that the alarm is broken and someone needs to get that fixed. After about thirty false alarms, you’re feeling like going out there and busting up the car yourself – especially if the car alarm wakes you when you’re asleep.

So alarms can be good, but if there are too many “false positives” – in other words if they go off too much when nothing is wrong – people tend to become tired of listening to them and eventually ignore the alarms.  On the other hand, if there are too many “false negatives” – meaning that they don’t go off when something is wrong – then the alarms aren’t fulfilling their purpose.

The same problem holds true for multiple types of alarms. Think about virus alerts on your computer. If they are set to alert you about everything, the first few times you freak out, then, after investigating, you dismiss them. If they alerts keep occurring too often, eventually you figure out a way to disable them. If the alarms don’t alert you when a virus is trying to hack into your computer … then what good is it to have the software?

With electronic medical records, medical providers are often alerted to multiple types of medical problems with each patient. No recent tetanus shot. Haven’t asked whether the patient is abused at home. No allergy information available yet. Time that patient was first evaluated not entered. Did you review vital signs? The list seems endless sometimes. Some of these alerts are useful. Most just serve to document some government mandated question that we must answer in order to receive payment for billing or to look like we provide better care on some database that only hospital administrators and reporters ever look at.

It was busy as heck during a shift and I kept getting knocked off task by alarms which are supposed to be helping us. A patient is having an acute heart attack. I try to put in orders for basic treatments and labs. Once I get logged into the patient’s chart, that takes a minute or so. Then, before the system will accept the orders, I get the alerts.
“No medical allergy information had been entered for this patient. Medication orders will be canceled.” The only button to hit is “OK” on that screen. Well, he’s a new patient. So I have to spend another few minutes clicking through a dozen or so screens to tell the computer that the patient has an allergy to sulfa drugs (causing him to have an upset stomach) and to iodine (which gave him a “warm” feeling when he received dye for a CT scan once).

Phew. Close call.

Then I spend another few minutes re-entering all of the medications I want the patient to receive. I have to enter all the medications by hand now instead of clicking on the boxes since the computer system won’t let me enter the same “order set” twice on the same patient.

First, let’s give the patient some aspirin. Everyone knows that’s an important treatment for patients having a heart attack.


Sulfa Allergy Aspirin

Alarm. Now I have to go through a few more screens and enter my password to confirm that I dare to give aspirin to a patient who gets an upset stomach when he takes sulfa medications. Where the connection is … GOK.

Well, I’ve dodged that bullet. Now let’s start an IV so that we can give him some IV fluids and have access to give him other medications if he needs them.


Iodine Allergy Saline

Alarm. Now I have to go through more screens and enter my password to confirm that I dare to give salt water to a patient who felt warm after receiving CT scan dye. Where the connection is … GOK. Salt water contains three things: sodium, chloride, and water.

Now that I’ve averted that disaster … oh yeah, the patient has a history of GI bleeds and was pretty anemic last time he was admitted to the hospital. Let’s get a type and screen on him too, just in case he needs blood.

“Reflex order: Blood transfusion.
“How many units of blood will patient receive?” Um … zero. We’re just doing the preliminary stuff if he should need blood.
“Should patient receive Lasix with blood?” Um … no. We’re not transfusing him yet.
Nevermind. Cancel the blood. Cancel. Cancel. Cancel. Yes, I’m sure I want to do that. Confirm.

OK, now let’s … wait a minute. Where was I? Oh yeah. Trying to take care of the patient having a HEART ATTACK.

In creating a “safe” environment for patients, the medical records have delayed me from providing necessary and time-sensitive care to a patient.
Now imagine going through the same or similar scenario multiple times each shift. Every shift.

Ready to go bust up someone’s car yet?


Proving a Negative

Thursday, April 11th, 2013

Skull Medical book [morguefile.com]A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem.

Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms.

The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier.
No old records in the computer.
I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any.
I asked her to show me her drivers license. Nope. Didn’t have that, either.
I was quickly developing an opinion that this was a snipe hunt.

Snipe hunts like this are an example of another conundrum that many physicians face.

We are often expected to prove a negative.

Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible – don’t comment with all your weight loss feats] that any patient could lose 50 pounds in a month.

But what if …?

What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for?
What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities?

Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem.

I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready.

A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups?

And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation.

I’m going to be eating my words if she comes back next month weighing 80 pounds.

Increased Workload = Increased Medical Errors?

Friday, March 1st, 2013

They throw around that lame 98,000 preventable deaths per year statistic, but the survey is still quite telling.

More than one third of 890 hospitalists surveyed stated that their workload exceeded safe levels on at least a weekly basis.

As a result of this increased workload, 22% of doctors stated that they had delayed admissions or discharges, 10% stated that they had failed to promptly note/follow up/act on a critical lab value or radiology report, and 7% stated that they had made a treatment or medication error.

In addition, 22% of doctors believed that they had ordered potentially unnecessary testing, 12% believed that the quality of care they provided had worsened, and 5% said that it was possible/likely/or definite that a patient died due to the increased workload.

As more and more doctors become employees of hospitals, I wonder how long it will take before hospital CEOs and administrators start being named in malpractice lawsuits (no malpractice caps on non-physicians, folks) for inadequately staffing the hospitals.

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