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The sleep doctor question

An article in the July 1, 2011 Los Angeles Times, titled “Limiting resident physicians’ work hours to save lives” again raises the question of whether resident fatigue affects patient care. I assume there is no coincidence that the article appeared the day that the newly minted physicians began training. The article, co-authored by Lucian Leape, MD, chair of the Lucian Leape Institute and adjunct professor of health policy at Harvard School of Public Health and Helen Haskell, founder of Mothers Against Medical Error, cites studies that go back at least 40 years demonstrating that fatigued residents make more mistakes than well-rested residents.

New rules limit first year residents to shifts no longer than 16 hours, and more senior residents to 28-hour shifts. When I was in training, my surgical brethren and I thought that if you were only on call every other night, you missed half of the interesting cases. I wonder whether today’s residents are as “tough” as we were back in the day. Should slave labor be reintroduced? Or are folks like Dr. Leape right?  Back in the day, we assumed our patients were safe and received quality care—were we right?  I don’t think so. So is 16 hours right?  Should it be 12?  Should it be less?  Should residency programs add a year to training programs so that residents can get the necessary experience, and still get some sleep?  What do you think?

Hospitalist-nurse partnerships

I have written in previous posts about the importance of developing partnerships between hospitalists and nurses. The quality of those relationships may determine the difference between a hospital that succeeds and one that fails. The key to a successful partnership is rapid flow of information between the parties and the ability to trust each other. Consider the needs of each side: hospitalists need nurses who can make accurate patient assessments and provide timely alerts to changes in condition, while nurses need physicians who provide clear instructions and provide rapid and respectful responses to contacts from the nurses.

Let’s start with the basics. Nurses need to know at all times which doctor is responsible for each of their patients. It is not acceptable for nurses to have to guess, try several doctors, or call an office to figure out which hospitalist is caring for a patient. When patient responsibility is transferred from one physician to another, the primary nurse needs to have that information promptly, and every hospitalist program needs a system to relay that information. If a nurse is confused and calls the incorrect physician, hospitalists should not dismiss the call with a brusque “Call Dr. X.” If the problem is simple and does not require detailed knowledge of the patient, handle it yourself and then refer the nurse to the appropriate physician for additional assistance.

The next level involves changing the work dynamics between hospitalists and nurses. Nurses document reams of information about patients throughout the course of a day, most of which physicians ignore. Unlock that information by holding a daily meeting in which physicians and nurses share their knowledge about patients. Formal rounding is great if you can do it, but a quick huddle with the nurse to go over the nurse’s observations about the patient and the doctor’s plan for diagnosis and treatment can be tremendously valuable in speeding treatment plans and in reducing phone calls during the remainder of the day.

The final level involves breaking down the wall between the professional status of doctors and nurses. If the patient asks for a cup of water, do you need to ring for a nurse? Would it kill you to fill a cup from the sink and bring it to the bedside? If you do a bedside procedure, how about taking the used items and placing them in the proper receptacles? A little bit of humility goes a long way in helping nurses feel that they are valued colleagues, rather than servants.

The downside to patient satisfaction scores

There is a theory of publicity that contends, “It doesn’t matter what you say about me, as long as you spell my name correctly.” Hospitalists have gotten lots of publicity over the years, and the name is usually spelled correctly. Most of the articles have been positive, including one that appeared in the New York Times on May 26. What was startling is the comments posted by readers. Nineteen readers reported negative experiences with hospitalists involving themselves or a family member. Two readers reported a favorable experience. One reader described an unfavorable experience when managed by a subspecialist and would have preferred to have a hospitalist. The concerns basically stem from poor communication with the patient, the family, and the primary physician. This is consistent with the generally low patient satisfaction scores reported for hospitalists.

ABMS and ACGME update core competencies: Don’t forget about procedural skills

The American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) announced an increased focus on procedural skills, according to a joint September 30 press release issued by the two organizations.

ACGME and ABMS is updating the six core competencies for physician performance measurement since they defined them in 1999. Procedural skills is categorized as a subset of the patient care core competency for which trainees and board-certified physicians must demonstrate proficiency. The competency previously known as “patient care” now will be referred to as “patient care and procedural skills.”


The direct approach

An interesting discussion took place on the American College of Physician Executives listserv recently. Someone posted a question about guidelines for accepting direct admissions to the hospitalist service from physician offices. I have always been wary of this practice because the patients are often too sick to be sitting in the admitting office or not sick enough to be in the hospital at all. The responses to the question were very illuminating and caused me to alter my thinking in this area. Some hospital medicine groups find that direct admissions work well for them and are an excellent way to draw referrals from primary physicians. Others feel that very careful screening is needed to avoid negative outcomes.


Atul Gawande: Why healthcare should be like baseball

Atul Gawande, MD, MPH, presents the keynote address at the AHRQ annual conference in Bethesda, MD, on Tuesday. (HCPro Photo / Karen M. Cheung)AHRQ plenary session

Atul Gawande, MD, MPH, gave the keynote address at this week’s Agency for Healthcare Research and Quality 2010 Annual Conference in Bethesda, MD. Gawande is a surgeon at Brigham and Women’s Hospital and the Dana-Faber Cancer Institute, associate professor at Harvard Medical School, both in Boston, and, perhaps, is best known for his work as a staff writer for The New Yorker and a New York Times best-selling author.

Among some of the inspiring words was Gawande’s proposal that the healthcare system use science to improve patient safety and change the culture of medicine.

Why healthcare is like baseball
Ringing a bell with Boston attendees, Gawande referenced former Red Sox general manager (now Oakland A’s general manager) Billy Beane’s approach to baseball. Using statistics, Beane recruited Kevin Youkilis and acknowledged his ability to get onto first base, despite his reputation for being a pudgy and poor third baseman. Youkilis went onto become a two-time World Series champion.


How much health did you make today?

Two articles in the August 12 issue of the New England Journal of Medicine highlight the difficulty in assessing the work product of physicians. The first article, “Quality Measures and the Individual Physician,” describes the difficulties encountered by a primary care physician, Danielle Ofri, MD, PhD, in achieving desirable scores on process measures, such as glycohemoglobin and blood pressure.

The second article, “Accountability Measures—Using Measurement to Promote Quality Improvement” (by Mark Chassin and others) outlines a method for ensuring the validity of measures used by regulatory agencies. Many of us find ourselves in a predicament similar to Dr. Ofri—measured against processes that she is seemingly unable to influence. Incentives are proliferating in hospital medicine and most are based on compliance with various aspects of evidence-based medicine. Does this actually make patients healthier? I do not know.


Doctor accused of unnecessary stents: What happened to the peer review process?

It’s every hospital’s, doctor’s, and patient’s worst nightmare—a doctor allegedly committing fraud, a stack of lawsuits, and claims of complications after surgery. Each member involved in the cardiac stent cases at St. Joseph Medical Center in Towson, MD, continues to be more entwined as the story unfolds.

The Maryland Board of Physicians investigated and this month met with Mark G. Midei, MD, for “gross overutilization of healthcare services” and “willfully making a false report or record in the practice of medicine,” among other violations of the Maryland Medical Practice Act, according to a June 11 Baltimore Sun article.


Do doctors understand patient costs?

Last week, I went to the optometrist for my annual checkup. I expected to get a new prescription for glasses and contacts. I didn’t expect a prescription for eye drops for my allergies. My doctor asked if I had been experiencing itchiness in my eyes, and I mentioned for the last week or so, I had. “How thoughtful of the eye doctor to ask,” I thought. He prescribed an olopatadine hydrochloride ophthalmic solution.

When I went to pharmacy to fill the prescription, I was shocked to find that the medicine, not covered by my insurance, costs more than $100; I had been using inexpensive over-the-counter eye drops. Had my doctor known how expensive the medicine he prescribed actually was? Why would he suggest them? Do doctors, in general, understand the costs of drugs, labs, and other services?


Will health reform increase hospitalization?

As health reform is being implemented, many wonder what it will do to patient volume in the hospital. Providing insurance to otherwise uninsured patients could mean an initial overwhelming number of ED visits and inpatient hospitalizations. However, reform eventually might decrease hospitalization if patients are seeking primary care more and thus, preventive care.

Take the poll below to see what your peers are saying. Comment below to have your say.

What budget conscious bundled payments mean for hospitalists

Yesterday, Kirk Mathews, MBA, discussed the Society of Hospital Medicine’s (SHM) developments in public policy work, particularly on talks with DC legislators about the prospect of bundled payments.

We spoke with contributing blogger Richard Rohr, MD, MMM, FACP, FHM, during the 2010 SHM annual meeting, about how bundling will affect hospitalists’ treatment and patient care.

Q: With broader access to healthcare, more patients could mean an overwhelmed system that already suffers from physician shortages. What’s the solution?

A: The key is we’ve got to figure out how to provide more care more efficiently. The hospitalists themselves need to be more self-reliant. We need to have more people who are confident in their diagnostic and treatment abilities, relying perhaps on resources like UpToDate rather than relying on a specialty consult for every problem.


Emergency department news round-up

It’s only Tuesday, and this week has already seen several stories pertaining to emergency departments crop up in the news. Check out what these news sources are writing about EDs:

  • The Wall Street Journal reports on the busy ED scene in downtown New York since St. Vincent’s closed in April. Four downtown EDs are picking up the slack, and it’s not easy.
  • USA Today reports on the drivers of over-testing in the ED. Any guesses? Physicians’ fear of being sued for malpractice tops the list, and patient demand for tests pulls in a close second. 
  • The Atlanta Journal & Constitution reports on acute psychiatric patients being forced to wait a week in the ED before being placed into a treatment facility.  Some are given little more than a chair to sit in while they wait.
  • The Associated Press reports on the rising number of ED cases related to overdoses on prescription painkillers and sedatives, which now trumps the number of patients who are treated in EDs for overdosing on illegal drugs. This startling trend may be related to the increasing number of prescriptions physicians write for painkillers and sedatives.