Archive for the ‘Policy’ Category
Wednesday, May 1st, 2013
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.
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.
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?
Thursday, April 11th, 2013
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.
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.
Wednesday, February 13th, 2013
California doesn’t have enough doctors to provide healthcare to newly “insured” patients under the UnAffordable Care Act.
California state senator Ed Hernandez asks “”What good is it if they [state citizens] are going to have a health insurance card but no access to doctors?”
Wait. Health care insurance doesn’t mean that patients will have access to health care? Where have I heard that being said for more than 3 years?
The government is going to give patients their medical “insurance,” but access to physicians is limited by government policies, payment cuts, and administrative red tape — which are driving many doctors from the primary care business and are, in effect, rationing care to patients.
California’s grand plan is to allow physician assistants, nurse practitioners, optometrists, and pharmacists to provide primary care services. I liked one of the commenters who said that he went to see the doctor, but was referred to the janitor who gave him a bag of medications for $5. These other health professionals and their organizations seem to naively think that the patients they will treat only require management of simple medical problems. In reality, most patients have multiple interrelated chronic medical problems that must be managed together.
Take diabetes, for example. Will it really be cost effective to have an optometrist manage a patient’s diabetes and perhaps monitor the patient’s diabetic retinopathy while the patient still has to be assessed and monitored for diabetic nephropathy, diabetic wounds and wound care, diabetic neuropathy, the increased risk of heart disease, oh and the impotence that often accompanies diabetes? Should the optometrist prescribe Viagra for a diabetic patient with heart disease or not?
If the optometrist refers the patient to a bunch of physicians to make those decisions, then the government has just created an additional layer of bureaucracy which will cost more money.
If the optometrist just blissfully monitors the patient’s glucose levels, prescribes insulin and doesn’t regularly evaluate the patient for diabetic complications, then the patients are receiving government-sanctioned poor medical care. That should make the trial lawyers happy … if the optometrists have insurance for the millions of dollars in damages when bad outcomes occur.
These health care providers are begging to get in over their heads and we need to let them do so. The medical establishment should really stop fighting this idea.
Allowing governments to implement a system that reduces access to doctors, increases complexity in medical care, and that will likely increase bad outcomes will eventually create patient outrage with government officials who adopt the idea.
We all should be part of a team, but not everyone is able to play quarterback.
I predict that these types of policies, if implemented, will ultimately increase the demand for physicians.
Unfortunately, the underlying problem is that most of us will be expected to pay more in “taxes”, insurance premiums, and other fees … for less medical care.
But remember that everyone will be insured, so things will be OK.
In anticipation of hate mail from nurse practitioners, physician assistants, optometrists, pharmacists, and possibly even Lucy VanPelt expressing outrage at my unprofessional stance because there aren’t any studies showing worse outcomes in medical care provided by those with less medical training, I’ll quote a comment that I posted on KevinMD’s site a couple of months ago in response to a nurse practitioner who asserted that he had “the same ability to provide patient care [as physicians] based on the evidence.”
You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than that rendered by nurse practitioners, so next down the line to help patients save money will be gifted grade school student phone advice and then Shaman Skype toddlers with their magical rattles of health. Goo goo ga ga.
I don’t care how good you think you are, if you can’t pass a doctor’s board exam, you shouldn’t be [independently] treating patients, so lose the ego. Actually, the law says that you can treat patients, but you damn well better tell the patients that you aren’t a doctor and then let the patients decide whether they trust you with their lives. But lose the ego, anyway. It’s a team sport and you don’t get to be the captain just because you think you’re better than everyone else. When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.
Wednesday, February 6th, 2013
JustADoc commented about a Yahoo News story concerning an obstetrician who posted a mini-rant on Facebook about one of her patients always being late. The obstetrician’s post said
“I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?”
After the post became widely distributed, some people called for the doctor to be fired. Others defended her as a good physician.
The hospital assured all their concerned patients that the hospital would “reinforce their high employee standards.”
The Yahoo news story created a fake retort from the obstetrician’s hospital (I looked up the hospital’s Facebook page to make sure it was a fake retort) saying
When I look back at my post last week about State Medical Board investigations for what are deemed to be inappropriate online posts, I started thinking.
If people agree that doctors’ livelihoods and the money and time they spent on their medical educations should be threatened because of a potentially offensive statement, shouldn’t that be the standard for everyone else as well?
An offensive statement is made by a hospital, investigate the administrative staff. Maybe fire them and blackball them from further jobs in hospital administration.
Politicians make an offensive statement, investigate them, too. Maybe they get fired and prevented from working as a politician. Same for CEOs, federal workers, journalists, editors, public employees, judges, lawyers … everybody.
Anyone receiving government assistance gets the same treatment. Make any offensive statements and you get investigated. If the statements are offensive enough, you’re on your own. You are no longer eligible for government assistance.
I agree … in all cases.
Saturday, January 26th, 2013
One of the posts in my Twitter feed was a re-tweet of something asserted by Dr. Art Kellermann (@ArtKellermannMD). Dr. Kellermann is a distinguished physician. He is the Director and VP of Rand Health. At one point he was a professor at Emory University, but apparently does not practice emergency medicine any more.
Dr. Kellermann’s tweet said the following:
Dr. Kellermann’s tweet references an editorial article that he wrote in the Annals of Emergency Medicine titled “Waiting Room Medicine: Has It Really Come to This? The article was from 2010, so I’m not sure what prompted him to tweet about it in 2013, but nevertheless, the article at least seemed pertinent … until I read it.
The assertion in Dr. Kellermann’s tweet was a quote from his article and was reportedly supported by a 2001 brochure created by the UK Department of Health (.pdf file). The context of Dr. Kellermann’s assertion in the article he wrote is as follows:
The ED is more than a clinical setting; it is a “room with a view” of the best and worst of modern health care. In the United Kingdom, a crowded ED is considered a telltale sign of a poorly managed hospital. If that perspective ever takes hold on this side of the Atlantic, things will change. Until then, it is up to us.
Things will change if our perspective changes. Until then, change is up to us.
What a feel-good nonsensical assertion of nothingness.
Monday, December 3rd, 2012
We were away for the weekend, but in a restaurant, I caught glimpses of this segment on 60 Minutes called “The Cost of Admission.” Couldn’t hear the conversations in the restaurant, but luckily CBS posted the entire report online. If you didn’t see it, you really need to watch the video and/or read the transcript.
In summary, 60 Minutes spent a year investigating irregularities in hospital admissions. Administrators at Health Management Associates and at EMCARE (one of the national emergency medicine contract groups) were accused of putting pressure on emergency physicians to admit at least 20% of patients that came to hospital emergency departments. For Medicare patients, the “benchmark” for admissions at one hospital was allegedly 50%. The 60 Minutes expose also included spreadsheets showing comparisons of different physicians’ admission practices and text from e-mails saying such things as “I have been told to replace you if your numbers do not improve.”
HMA held a conference call disputing the allegations and stating that they “take all allegations regarding compliance very seriously.” HMA allegedly had outside experts review the data (not the medical records?) and the experts determined that “the data simply do not support the allegations.”
Now HMA is being investigated by the US Department of Justice for Medicare fraud. I predict that HMA will make a large settlement with the government to drop all charges (without admitting wrongdoing, of course) and that things will return to business as usual shortly thereafter.
With things like this, I can’t really blame patients for thinking that medical care is “all about the Benjamins.”
Patient satisfaction metrics are creating quite similar incentives with physicians. How long will it be before people wake up and see how much fraud that the satisfaction scores are causing?
Tuesday, November 13th, 2012
Retired emergency physician/family physician writes letter to editor of Minnesota newspaper stating that insurance should pay for birth control for all women because otherwise rich women could afford to pay for birth control and poor women would be forced to have unwanted children or “back-alley abortions.”
I’m not really sure how someone too poor to purchase birth control is going to be able to purchase insurance so that they receive free birth control via a government mandate, I’m also not sure how people too poor to purchase birth control are going to be able to afford to pay for a “back-alley abortion” on such limited income.
That’s OK. No one ever said that mandates have to make sense or have logically justifiable reasoning to support them.
He’s missing the simple solution to this problem.
Everyone should just be able to pick up as many condoms as they want at any federal building for free. Go drop off your mail, grab a handful of condoms. If government is going to mandate it, the government should pay for it.
Think about it: No worry about adverse side effects from “the pill.” No discrimination against males who don’t get to share in the free handouts. Plus, consider the added bonus of decreasing the spread of sexually transmitted diseases.
If they were smart, they could even sell political campaign ad space on the packaging. Then again, if that happened, people might get confused and think that the pictures are showing where to put the condoms.
Sunday, November 11th, 2012
This was one of the patients I submitted for Nurse K’s Dr. No BS contest. By my calculations, I was the unofficial winner in said contest, but I don’t want to brag.
The case involves what one of my old mentors used to call his “Spidey Senses“. Something just doesn’t seem quite right. You can’t figure it out, but something tells you that you need to dig deeper. Most of the time, the Spidey Senses are just a false alarm and you end up performing what some people deem an “unnecessary” test. Hey, even Spiderman wasn’t always right. But in a select few cases, listening to your Spidey Senses (and sometimes ordering “unnecessary” tests), can help to make an important diagnosis.
Psych wonks may use the term “cognitive dissonance” to describe the Spidey Senses. I’m leaving the post title as “Spidey Senses” because prolly no one would read a post about cognitive dissonance and because I couldn’t find a cognitive dissonance picture.
A 50-year-old man came in with R shoulder pain for about a week. He was already going to a pain clinic for low back pain, and that day he went to the pain clinic for a re-check of his shoulder pain. The doctor at the clinic prescribed him Neurontin for his shoulder pain and the patient came to the emergency department because “that stuff doesn’t work.”
He said that his shoulder pain was bothering him so much that now his right side was killing him, too. In fact, he wouldn’t lay back on the bed because of the pain. His wife sat next to him helping to support him while he was sitting as he slumped over to the right side and didn’t answer many questions because he was in too much pain. The patient’s wife did most of the talking.
I have to admit that my initial impression of this gent was tainted by the whole pain clinic story.
Maybe he was coughing from his pack-and-a-half day smoking habit and strained a muscle in his chest wall.
Pain from a gallbladder attack can cause referred pain to the right shoulder when the inflamed gallbladder irritates the diaphragm. Maybe he’s having biliary colic.
Maybe he had a pneumothorax.
Maybe he was doing something he shouldn’t have been doing and injured his shoulder, but he didn’t want to tell me.
But come on, now. Pain so bad you can’t even talk to the person trying to help you? Call me skeptical.
Sunday, September 9th, 2012
By Birdstrike M.D.
Once again, our upcoming election will have great impact on future health care policy. Obamacare will either be kept intact, repealed or altered. This will have great impact on patients, physicians in general, and especially Emergency Physicians. By whom they choose to lead us, the electorate will decide whether treatments are rationed or not, and if so, to what extent, by whom and on what basis. They will decide whether doctors are free to choose what tests to order, and if so which ones, how many and for what reasons. Also, they will influence physician salaries, by choosing the leaders who will determine Medicare and Medicaid reimbursement, which generally lead with reimbursement cuts that private insurers follow. Our electorate will determine our malpractice liability by choosing our leaders who will either, strengthen, weaken or ignore tort reform. They will influence which charting systems we are required, or not required to use, given that Obamacare has already written into law penalties for failure to implement electronic health record use. By whom they choose to lead us, the electorate will influence how much we are, or are not burdened by regulations, and whether these regulations will be logic based, or cumbersome and irrational.
The choice of the electorate will affect which pay for performance measures we and our salaries are subject to. Likely, they will also influence which form of patient satisfaction surveys we are or are not subject to. Also influenced, will be our overall workload depending on whether patients are adequately insured, by which doctors and in which settings. This will influence who is most, or the least burdened by the overall shortage of healthcare providers, and whether or not the millions of newly insured will end up in primary care physicians’ offices, shunted to emergency departments with growing wait times, seen in specialists’ offices or remain uncared for. How informed, or uninformed our electorate is, particularly as it relates to health care policy, will affect the health of our patients, our livelihoods as physicians, not to mention the health of our families and ourselves as patients.
Since the end our nation’s two major party conventions, it caught the attention of several major news organizations that on any given night of the week of either the Republican or Democratic National Conventions, that both parties faced stiff competition for viewers from the new and controversial TV show on TLC called “Here Comes Honey Boo Boo,” which TLC describes on its website as a show where a “six-year-old pageant sensation proves that she is more than just a beauty queen.” As said by the child’s own mother, June Shannon on ABC News, “We are a little redneckish, and we live in Georgia and that’s what people do in the country — get muddy and have fun with the family.” In the first episode they take part in the “Redneck Games,” bob for pigs feet and take part in a “mud pit belly flop.” Although fortunately the overall viewership of the conventions was greater according to ABC News, this show did draw more viewers than Fox News’s coverage of the Republican National Convention on at least one night and tied the ratings of the Democratic National Convention during Bill Clinton’s speech. Does anyone know where Honey Boo Boo stands on health care?
Apparently, a large part of our electorate would prefer to watch a show like TLC’s “Here Comes Honey Boo Boo” over either convention. Whether this is more of a reflection on our political parties, our electorate, our “Democracy” or (hopefully) none of the above, I am not sure. However, two months before an election where we will choose a President, seat our entire House of Representative and 1/3 of the U.S. Senate, that will have a huge impact on future health care policy, I think it is worth discussing how informed or uninformed, and how engaged or apathetic our electorate is about the health care issues at hand. Their decision will affect our patients, our health, our work environments, our salaries, and countless details of our health care system going forward. It is our responsibility as physicians to educate the public on this part of their vote and its potential consequences.
Have we done our job as physicians to educate our patients, friends and co-workers on the issues at hand and how important this election is? Have we come to grip ourselves, with how much this current election will affect the lives of our patients, our families, as well as every aspect of our profession? If the answer to either question is no, then between now and Tuesday, November 6th 2012, we have a lot of work to do.
Which did you watch, the Republican Convention, Democratic Convention, or “Here Comes Honey Boo Boo”?