Wednesday, December 28, 2011

Life at Grady: Mentors

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor. It is reprinted with permission.

One of the first things people tell you when you take a faculty position in medical education is this: "Get yourself a mentor." It doesn't matter if you're a clinician educator, a clinician researcher or both. At some point somebody is going to catch you at the coffee maker and ask you all nonchalantly:

"So. . . .who's mentoring you?"

This is the point where you break out in a cold sweat. Unless, of course, you have a clear idea in your head exactly who that person is. Maybe you're so savvy that it's more than one person, even. But if you are like many fairly junior folks, that answer isn't as clear as you'd like for it to be.

Here's why. Many institutions help you identify a mentor right from the start. Someone looks at you and your accomplishments and serves as a professional "match.com" for you and your future. The problem is. . . as well meaning as these arrangements are, ofttimes it doesn't result in "eharmony."

And so. You give that name that was given to you whenever someone asks, but secretly you kind of recoil because there hasn't been the kind of magic you'd been hoping for.

I know that some professional person somewhere is reading this thinking, "Yes! Yes! Yes!" Yes, because it's true.

At this point, a few of you might be saying, "What do you mean 'mentor'? Is it like having a guru? Because if it's that, I'll pass, thanks."

(Click "more" below to keep reading)

Alright, so check it. Back in the Greek mythology day, Odysseus (as in the dude behind "The Odyssey") had this right hand man named Mentor (yes, this was the dude's real name.) Anyway, Odysseus had some big things going on--and by big things I mean The Trojan War. Odysseus, being the responsible dude he was, was concerned about who would hold things down for him in his absence. And remember when I said that all women need good women friends and all men need good men friends in their corners? Fortunately, Odysseus had that in his running mate Mentor.

Odysseus had a son who was the apple of his eye named Telemachus, and he needed somebody to keep an eye on his boy while he was away. Even though Telemachus wasn't a baby or anything, this was necessary because his father was kind of a big deal. So, in a way, Mentor was kind of like having secret service for the Obama girls but like, before the secret service was invented.

So the story goes on, a lot of stuff goes down, but the bottom line is that Odysseus' Mentor held down the fort big time and proved to be a great guide to Telemachus. When it was all over, Telemachus probably said, "'preciate you" to Mentor and Mentor, like any good mentor, just smiled all proud-like and replied by saying something poignant like, "Ah, my lad. . . . when you succeed, I succeed."

This is where that whole word comes from in the English language. The gnarly thing about the story of Mentor is that he wasn't just a babysitter. He was wise counsel, a cheering section, a coach, and a trusted confidant. And although Telemachus had a good father who could serve in that capacity most of the time, it ended up being good to have someone else in that role as well.

So I say all this to say...I think good mentors help us to get close to our full potential. We all need good mentors to nudge us, advise us and sometimes taze us into doing what we need to do. The most effective mentors coach, inspire and lead by example. It took me a minute (a Grady minnute) to recognize and identify my mentors in medical education. And man, am I glad that I finally did!

Haven't found one yet? Or don't realize who yours are? Never fear because today, in the first installment of my Mentor-ific series, I bring you:

The Top Ten Ways to know a GREAT mentor when you see one.Use this to help guide you to the promised man or wo-man. (Not in the romantic sense but in the mentor sense, alright?)

Drumroll please. . . . . .

#10 -- R-E-S-P-E-C-T

A mentor that's right for you is someone that you respect. Now, this is trickier than you might imagine. Just because someone is a rock star professionally doesn't mean that you'll fully respect them. Perhaps you don't like the way he or she speaks to his or her administrative assistant, or that they never leave work to be with their family. Whatever it is, if there's a disconnect in your ability to feel genuine respect for the person, it's probably not a good fit.

#9 -- PRODUCTIVE

It's kind of ideal to have a mentor who has actually done some of the things that you aspire to do. Don't confuse that for EXACTLY the things that you want to do.

Case in point: My main professional mentor is NW., who happens to have some interests that don't exactly mirror my own. But. He is a highly accomplished teacher on the local, national and even international levels. His teaching style is quite different than my own, too. And that's fine. Because he is very, very productive and helps me to push harder both through his encouragement and his example. Plus he's a greatteacher, which I always aspire to be. I respect that. It works.

#8 -- AVAILABLE

Doesn't matter how amazing of a fit a person is for you if they don't have time for you. Some folks are well-meaning but ridiculously busy. Too busy to reply to your emails or your phone calls. And if that's the case? Regrettably, it's probably not a good fit.

There are some times when the mentee falls short and isn't assertive or prepared enough. This might leave said busy potential mentor less than enthusiastic about making time for them. But when it's not that, then at some point you just have to cut your losses and keep it moving.

Yes, you are published in the highest tiered rock star journals and you present at the biggest deal conferences every year. But you won't call me back so . . . . oh well.

#7 -- WISE

A great mentor has been around the block enough to have gained some wisdom here and there. Sometimes you need to turn to your mentor for insight on what to do when those paths diverge in a yellow wood. It helps if they don't have to use an eight-ball to give you some advice.

#6 -- EXAMPLE

Those I identify as mentors are people whom I consider role models. Not just professionally, either. I like knowing that, yes, you work hard but that you also go on vacation with your family or take a cooking class with your husband on Tuesdays after work. No, you don't need to be perfect. Just working to achieve some sort of balance, you know? It also helps if you're nice.

By the way--I gave a speech once called "Let your life be a mentor." It was about how even when folks don't know you personally, they can be mentored by your example and the lessons in your life. I am mentored, for example, by Angella L. on many things. She is a mom and professional and a wife and when I read her writings, I get guidance. That's just a little bit of food for thought.

#5 -- UNSELFISH

I'm sure Mentor had a whole bunch of things he needed to do while Odysseus was gone to the war. Even though it is technically a myth and was technically waaaaaay back when, I know for sure that not that much has changed in the world since then. Real talk? Time is a precious thing. This is why many people would much rather write a check toward food for the homeless than going to a shelter and actually feeding them. Time. Energy. Commitment.

It takes an unselfish person to spend time focusing energy on someone other than themselves. Exceptional mentors are willing to sacrifice their time, ideas, and energy to bring out the best in you.

Oh, and don't be fooled. Sometimes productive mentees find themselves working with people who seem unselfish. Ask yourself a question: Would this person still be as interested in working with me if they weren't last author on all of my papers in their field or if I wasn't completing the manuscripts that were sitting on their desk for the last five years? If the answer isn't an immediate absolutely yes, then know that the relationship could be difficult to sustain.

#4 -- INSPIRATION

Mentors come in all shapes and sizes. Some serve as "coaches". They stand on the sidelines watching you and telling you how to improve your technique. They come up with ideas that you never thought of, point out strengths and weaknesses that never occur to you, and. . . .they just. . . .they just invigorate you.

One of my mentors who serves in this capacity is a Grady doctor named CD. CD is quite possibly the busiest, most hard-working person I know. But he does all of the things he does with such zeal, man. He teaches with zeal. Treats patients with zeal. And even responds to my most simple text messages with a spunk that often makes me laugh out loud. I learn so much from watching him and listening to him. And though he is not my mentor in the formal sense I count him as one because he makes me better.

There's a whole movement about peer-mentoring that I have to mention here, too. Many of my peers in medicine hype me up so much! I watch them teach or talk or do what they do and I feel invigorated. Ready to try something new. That list is long. But I count these people as the swirling moons around me that serve in a mentoring role, too.

#3 -- NO-COMPETE CLAUSE

Your mentor should NOT be in competition with you. Period.

#2 -- FUN

Mentor-mentee relationships can be time consuming. It sure can be painful to spend all that time with someone who's a stick in the mud. When I meet with my mentor we spend at least 70% of the time laughing out loud. It's productive, yes. But always fun.

Okay, except for the last chapter we wrote together. That wasn't fun. But he did laugh at all of my jokes regarding how un-fun I found that whole process. And the reason he insisted I do it was because he thought it would help me professionally. (He also helped a WHOLE lot with the hard parts which takes me back to number 5.)

#1 -- GENUINE INTEREST IN YOU.

Not what you can do. Not how fast you write. Not how willing you are to work long hours. And not just what you can do to make them look good.

You.

They remember that your son is turning five and they fly back from wherever they were to be at his birthday party because it's important to you. (Yes, I remembered that, NW.) They want to hear your ideas and have the patience to help you flesh them out. They take the time to look at your unique qualities and try hard to come up with the best ways to utilize them. They know when to push you and when to back off because they've taken the time to get to know you.

In other words, they care. About you. You. Even if you don't have great comic timing. Even if you got a 'B' on the medicine clerkship or if you didn't get awarded that big grant from the NIH. They still make room for you in their schedule and start that meeting off with simple things like:

"How are you? How was Harry's birthday? Are the kids out of school yet? Have you ever eaten at Antico Pizza?"

And then they get down to business. I think everyone knows that there is a very fine line between business and pleasure. It sure helps when it gets blurred.

Oh and mentoring isn't just a doctor thing or a medicine thing either. Many of my mentors coach me in life and motherhood and everythinghood as well. And. Many people mentor you without even knowing it. Kind of cool, isn't it?

Bottom line? The best mentors get it. And they get you.

Labels: Life at Grady, mentoring

Nearly 9 in 10 doctors stressed on any given day

The vast majority of U.S. physicians are moderately to severely stressed or burned out on an average day, with moderate to dramatic increases in the past three years, according to a survey.

Almost 87% of all respondents reported being moderately to severely stressed and/or burned out on an average day using a 10-point Likert scale, and 37.7% specifying severe stress and/or burnout.

Almost 63% of respondents said they were more stressed and/or burned out than three years ago, using a 5-point Likert scale, compared with just 37.1% who reported feeling the same level of stress. The largest number of respondents (34.3%) identified themselves as "much more stressed" than they were three years ago.

The survey of physicians conducted by Physician Wellness Services, a company specializing in employee assistance and intervention services, and Cejka Search, a recruitment firm, was conducted across the U.S., and across all specialties, in September 2011. Respondents mirrored the AMA 2009 Physician Masterfile, with 2,069 completed surveys representing a 99% confidence level with a +/- 3% margin of error compared to about 750,000 physicians. The survey respondent sample skewed more toward non-primary care practices by 11.1 percentage points, possibly reflecting a younger survey sample and fewer primary care medical school graduates.

The top four external stress factors are the economy (51.6%), health care reform (46.4%), Medicare and Medicaid policies (41.2%), and unemployed and uninsured patients (29.7%). Only 8.6% of respondents reported no external stressors.

The top four work-related stress factors are administrative demands (39.8%), long work hours (33.3%), on-call schedules (26.2%), followed by medical malpractice lawsuits, insurance company interference, conflict or disagreements with administrators, increased complexity of care and electronic health/medical records. Only 1.1% reported no stress from work.

The top three personal life-related factors were not enough leisure time (52.6%), not enough time for exercise or wellness (50.6%), concerns about work/life balance, in general (45.0%), followed by concern about finances or sleep. Only 8.4% of respondents indicated that there was nothing stressing about their personal lives.

The result of the stress is declining job satisfaction (51.2%), a desire to reduce hours (41.2%) and a desire to retire early (29.9%), nearly tied with a desire to leave the practice of medicine entirely for another career (27.6%). The next two were also related to changes in their work situation: desire to switch jobs (21.8%) and desire to switch to a new practice (15.9%). Only 6.9% of survey respondents reported no work-related stress.

Fourteen percent of respondents indicated they had left their practice as a result of stress, among whom 56.7% continued practicing, but in a different setting, 33.3% continued working in medicine, but in a different job or role, and 10 left medicine entirely. Most noted some improvement, with 42.6% each saying leaving improved their stress and burnout.

Not surprisingly, all the stress triggered tiredness (41.4%), sleep problems (36.7%) and general grouchiness (33.9%), personal health problems (24.7%) and conflicts with a spouse or partner (22.6%). But 9.1% of respondents reported no impact on their personal lives due to stress and/or burnout.

Most doctors handle the stress through exercise (62.8%) or time with family and friends (56.9%). The next cluster involved vacation (47.8%), movies or music (44.3%), reading (38%) and getting more sleep (35.8%). Mentoring, yoga, meditation or peer support were not as prevalent, and doctors commented that finding the time and, in some cases, money to do something was, well, stressful.

Nearly one-third of respondents indicated that better work hours/less on-call time and better work/life balance would help to reduce their stress. Nearly two-thirds of respondents said ancillary support would help. This feedback and the growing trend of part-time work schedules for physicians indicate a need for advanced providers such as nurse practitioners and physician assistants who can provide accessible and effective care as physicians scale back their hours in order to pursue better work/life balance, the companies said in a press release.

Labels: career choices, lifestyle, malpractice, patient safety, recruitment, work-hour limits

Holiday decoration-related ER visits: Are these statistics sending the wrong message?

Yesterday's American College of Emergency Physicians Member Communication e-mail (titled Emergency Medicine Today, in affiliation with BulletinHealthcare) had this as its top story: Injuries Linked to Holiday Decorating on the Rise, from a website called HealthDay News. The reported cites a U.S. Consumer Product Safety Commission press release, crafted with help from Underwriter Laboratories (the wire engineers).

They claim: "In November and December 2010, more than 13,000 people were treated in U.S. emergency departments for injuries involving holiday decorations, up from 10,000 in 2007, and 12,000 in 2008 and 2009, according to the U.S. Consumer Product Safety Commission (CPSC). A well-watered tree, carefully placed candles, and carefully checked holiday light sets will help prevent the joy of the holidays from turning into a trip to the emergency room or the loss of your home," said CPSC chairman Inez Tenenbaum in an agency news release.

Good advice. Though it's been said (many times, many ways. So when it came time for CPSC and UL to raise the topic, did we need the very questionable statistics to justify it?

If you're having trouble wrapping your head around the number of decoration-related emergency department visits, consider this similarly bizarre statistic: 8,000-10,000 kids are injured each year from falling televisions. So, for perspective: in the November to December period, Americans now endure more holiday-decoration-related trauma than an entire year's worth of falling TVs (though, now that I think about it, there may be some overlap, like if while putting up some Christmas lights, Dad knocks over the TV and it lands on Junior's foot. That could be one ED visit logged in both categories.)

Another way to think about it: 13,000 visits over two months spread over the approximately 1,800 EDs in the U.S. translates to about seven holiday-decoration-related visits per ED. Not much, when the average department sees 5.000+ patients a month (and Americans visit the ED 130 million times a year). I'm not even sure it's significantly more than it was a few years ago, when EDs could expect, get ready for it, six (6) visits related to holiday decorating.

Still, I've yet to see my first mistletoe-hanging trauma. I have seen more than my share of frankincense and/or angel dust intoxication lately, but I don't think that counts as a decoration-related ED visit.

In fact, I handle a lot of statistics and analysis for our ED, and I could not tell you how many holiday decoration injuries we've seen this year, or last. To really do it right (i.e., publication-quality data that could stand up to peer review or Joint Commission scrutiny) we'd have to build a query to retrospectively through the text of all patient notes, looking for mentions of menorah fires or tree-felling injuries, then do a chart review. Or we could code a checkbox and ask our triage nurses to prospectively screen for this, along with suicidality, domestic violence, and HIV.

Probably what CPSC is doing, instead, is drawing from a few statewide databases or surveys like NHAMCS and generalizing broadly (certainly, there are no scholarly papers on holiday decoration emergencies; the literature on falling TVs is much more robust).

Survey data is fine for identifying new threats to the population, or changes in abuse patterns, but it's hardly precise and when I see dozens of headlines about the rise in ED visits from holiday injuries (Google news counts 291 stories at the time of this writing) it makes me cringe. If next year's holiday decoration visits fall back down to 10,000, does that mean we've turned a corner on educating the public about the menace of holiday decorations? And so we won't need to be so vigilant anymore? Or is it just a statistical blip, well within the margin of error, not at all worthy of a headline?

And on that note, I must break off to do some holiday-related shopping, confident (but somewhat disturbed) in the knowledge I've now spent more time mulling this over than anyone involved in writing or selecting that press release for inclusion in ACEP's daily email.

This post by Nicholas Genes, MD, PhD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: emergency room, guest post, humor

Life at Grady: Slip Slidin' Away

The following post, by Kimberly Manning, MD, FACP, first appeared on her blog, Reflections of a Grady Doctor. Names and indentifying information have been changed to protect privacy.

You'd been sleeping for what seemed like three days. Your admission diagnosis was for a common reason--"altered mental status"--but what would happen next wasn't clear.

The first day they brought you in with soiled pants and underwear. Your body was limp like a rag doll, or better yet, like some sort of carnivorous animal shot with a tranquilizer dart and chemically restrained. Strong in body, muscular like the king of the jungle...but still and quiet.

Someone pushed their pointed knuckle deep into your sternum hoping it would arouse you but...nothing. Another doctor came and mashed hard on your finger nail with an ink pen while a medical student watched. "Noxious stimuli," the doctor said. "This helps me see if he responds to painful stimuli." The student nodded in acknowledgment.

That first day, you didn't respond to much of anything. Your loss of continence combined with the gash on the back of your head made someone think that maybe you'd had a seizure. That was enough to get the Neurology team in to see you. It was also enough to prompt several tests to be run on you including a spinal tap and an MRI.

By the time I got there, you had moved from somnolent to "groggy." Heavy eyelids, slurred speech, words that came out as nonsense--but this was better than how you reached the ER. I glanced at your arms and found them sprinkled with red dots like confetti. Next I saw the middle-aged woman whose pained expression from the bedside chair clenched the diagnosis for me:

Drugs.

(Click "more" below to keep reading)

You were too out of it to participate in that conversation, so on my first visit I just spoke with your mom. Watching how her lower lip quivered when she told me of your long battle with substance abuse and depression hurt me deep in my heart. Sips of alcohol in middle school. Then some marijuana. A few wild friends nudged you into harder things like powder cocaine and prescription pills. Before you knew it, this became too difficult to manage. You needed something quick and predictable to see you through the complexities of your mood disorder and your physiologic dependence.

"Heroin will help you not be sick." This was the word on the street so you clenched your teeth and got over that fear of needles that you'd had since your boyhood.

And from there things went crazy.

This was the story your mother gave me with her quivering lip and tired eyes. This wasn't the first time she'd been here.

When you finally woke all the way up, I happened to be there rounding. You were astounded at the fact that you were in an adult diaper and you asked about your mother right away.

"Oh my God. My mom--was she here?"

I nodded. "Her and, I think, your sister."

"Did my mom...agghhh...was she crying?" you asked while smacking your palm to your forehead. I noticed your fingernails then. Painted black.

"Not really crying. She was just kind of. . . ."

"Trying to talk with her lips trembling? She only does that when she's trying not to cry."

I didn't want to answer that so I just stood there staring at you. That was enough, though. You dropped your face into your hands. You swore. You balled up your fist and pounded it onto the bed.

I reached out and gripped the hand rail. I wasn't sure what to do.

"She's done this with me so many times. I'm so tired of dragging her through this." You punched the bed again, this time startling me.

"She didn't seem mad. I mean, she just seemed concerned," I finally said. I wanted you to feel better and this was all I could think to say.

"That's the freakin' problem. She's not mad. She freakin' forgives me and prays over me and lets me back into her house. And it's fine at first and then I mess it right up."

I bit the inside of my cheek awkwardly. I didn't really know what to do, so I just sort of stood there like I'd been frozen with some kind of remote control.

Your situation was different for me. I mean, yes, I have seen people addicted to intravenous drugs but in Atlanta at this hospital, it's definitely not the method of choice. I was used to hearing about relapses of crack cocaine and tales of bodies being sold to get hands on it. Bodies neglected from the full time job of smoking tiny white rocks in little glass pipes. And empty promises to get out of hospital beds.

You were this college educated person with blue blood lineage. The one whose behavior screamed black sheep but whose mother loved him like a precious lamb.

"Is it the craving...like...feeling sick that makes you keep coming back to it?" I asked this really dumb question, yes. But only because I was curious.

"It's the hating myself, really." You looked down at your arm band and twirled it on your wrist. "That's what makes it so hard when somebody is trying to love you through it. It's really, really hard to have someone loving you like that when you don't love yourself."

"Why do you think that is? I mean, that you don't love yourself?"

You pause for a moment and laugh. Your eyebrows raise and with a tiny shake of your head you replied, "Now that's the million dollar question, isn't it?"

I guess that was when I realized how dumb that question was, too.

"I'll get myself all clean and then it goes full circle. Feeling like I don't deserve to be happy."

"Hmmm." I tapped my fingers on my lower lip as I listened. Maybe it was out of nervousness or maybe it was to keep myself from saying the wrong thing. "Have you been talking to the psychiatrists still?

"I do. I mean, I always do. It's so messed up...you know? I realize that this isn't normal, you know? I know the drill...talk it out...get to the root of the pathology. What happened to you? What messed you up as a kid that now has you extra-messed up as a grown-up? See? That's what's so messed up. I can't put my finger on that thing...that one awful thing that allegedly started all of this."

"Pathology." "Allegedly." You were obviously highly intelligent and your insight was unreal. And you were right. I had no idea what the answer was to all of it. So I just sat there listening because honestly, I'm not a psychiatrist and I don't exactly know what to do with all of this information or even the first place to start psychoanalyzing any of it.

"Wow, that's deep," I said instead.

"Yeah, that's one way to look at it," you replied. Just then you looked down at the adhesive from the IV taped to your arm. Next to that was a scar from the IV drug use poorly disguised by a tattoo. You caught me looking at it and shook your head. "I bet you're thinking, What a waste."

I looked at you and thought about my words before speaking them. "That's not what I'm thinking at all."

You chuckled and covered the scar with your hand.

"I'm thinking I wish that you didn't have to be in this situation. You or your loved ones. I'm wishing I knew the key to making this go away."

"I know the key," you responded. That kind of surprised me. You put up your thumb like you were going to hitch-hike and then turned it in on your chest. Next came a big sigh and you added, "That's the problem."

I narrowed my eyes and nodded. "Do you pray?"

"Naah. Not my thing. That always seems to come up, but I don't know. It never has soothed me or made me feel anything."

I chose not to respond to that, recognizing that my first question on the subject was enough.

"So...it looks like you're recovering from the overdose. I spoke with your mother and she says she's willing to bring you back to North Carolina with her."

"Of course, she did."

"How do you feel about that?"

"Undeserving."

I reached for your hand and squeezed it. You let me.

"You're a pray-er aren't you? I can just tell you are. You probably have Jesus on the mainline, don't you?"

I smiled and released a little laugh. "Hmm. I guess that's fair to say. I think he even has a text package these days."

"Wow, man. L-O-L and O-M-G, literally," you retorted. That idea amused us both.

We sat there with our eyes locked and our hands locked, too.

You spoke first. "Well do me a favor, okay? Pray for me, will you?"

"I will."

"You promise?"

"I promise."

"And my mom, too, alright?"

"Got her covered."

After I finished up my exam and the necessary elements of the visit, I gave you a hug. Tight like the way a mother hugs a son. Something tells me that you felt that part of it. I sure hope you did.

That night I prayed for you. And never saw you again.

Labels: addiction, Life at Grady

Using GoAnimate to create case scenarios

Case scenarios are critical in medical education. They make the content more real and applicable to work and thus add value. This point was borne out during a recent course I co-directed on the use of technology in medical education. As a part of the course, physicians worked in teams to create eLearning modules.

Four out of the five teams chose to use an animated video to introduce their module. One of these team chose Xtranormal for their video but the three other teams chose GoAnimate. Physicians found it relatively easy to use these tools.

One of the most striking examples of these videos was one to help introduce the importance of describing a skin lesion.

Besides priming the learner for clinical content, these videos can be used as lead ins for training on communication skills or focused history taking. Here is a link to an animated video to lead in to a discussion on communicating with an angry patient.

Education technology folks working with faculty in medical schools or with residency programs should consider introducing these educators to use of animated videos in their teaching.

Summary of advantages of animated videos for medical education:
1) Relatively easy to create
2) Can be embedded or linked from any eLearning content or Learning Management System
3) Makes the course content more real and thus adds value
4) Makes eLearning more fun
5) Can you used as basis for a face to face discussion with learners
6) No HIPAA issues
7) Easy to share/disseminate

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

Labels: guest post, medical education, Neil Mehta, new technology, Technology in (Medical) Education

5 steps for flu prevention should include mandates for health care workers

Health care facilities should consider mandatory flu vaccinations for their employees if other attempts don't increase rates to 90%, a draft statement from a U.S. Department of Health and Human Services (HHS) working group stated.

All public health services, HHS staff and Federally Qualified Health Centers should follow suit, stated the Health Care Personnel Influenza Vaccination Subgroup in draft recommendations.

The working group released five steps to boost vaccination rates:
--Employers should establish comprehensive flu infection prevention programs as recommended by the Centers for Disease Control and Prevention (CDC) to achieve the Healthy People 2020 influenza vaccine coverage goal of 90%.
--Employers should integrate flu vaccination programs into their existing infection prevention programs.
HHS should encourage CDC and the Centers for Medicare and Medicaid Services to standardize the methodology used to measure health workers' flu vaccination rates, as well implement incentives, penalties or requirements that facilitate adoption.
--Employers and facilities that still can't achieve 90% flu vaccination rates among workers after following the three previous steps should strongly consider an employer requirement.
--HHS should encourage developing new and improved vaccines and vaccine technologies, including support for research, development and licensure of vaccines with better immunogenicity and duration.

According to the Advisory Committee on Immunization Practices, annual vaccination is the most effective flu prevention strategy. Immunizing health care workers protects them, keeps them at work during flu season and protects coworkers and patients.

The report notes that while vaccination is the best-documented and most effective intervention to prevent the flu, it's tough to definitively measure. Outcomes for patients varied widely between the studies considered by the working group.

Labels: influenza, patient safety, vaccination

Do doctors feel that they need permission to share ideas?

Let's say you're a doctor and you have an idea, opinion, or a new way of doing things. What do you do with it?

It used to be that the only place we could share ideas was in a medical journal or from the podium of a national meeting. Both require that your idea pass through someone's filter. As physicians we've been raised to seek approval before approaching the microphone.

This is unfortunate. When I think about the doctors around me, I think about the remarkable mindshare that exists. Each is unique in the way they think. Each sees disease and the human condition differently. But for many their brilliance and wisdom is stored away deep inside. They are human silos of unique experience and perspective. They are of a generation when someone else decided if their ideas were worthy of discussion. They are of a generation when it was understood that few ideas are worthy of discussion. They are the medical generation of information isolation.

I spoke with a couple of students recently about medical education reform. And as I often like to do, we discussed what was needed to prepare doctors for life in 2050. I picked up on the most remarkable ideas and suggested that they publish their views as a position paper or editorial. They looked puzzled, and for good reason. They believe that the simple expression of their brilliance is not their responsibility or even their right. It's that of some national professional body or editor. You need the keys to the kingdom to be heard. You need permission. You need to be invited.

In Poke the Box, Seth Godin calls this the tyranny of the picked: Waiting and hoping "acknowledges the power of the system and passes responsibility to someone else to initiate."

But the way the world communicates is changing. The barrier to publish is effectively non-existent. The democratization of media has given every physician a platform to the world. But the physicians have yet to speak up. We're preoccupied with how our voices will sound. We pine over what someone might think. We're too concerned with how we'll look and not concerned enough with how our thoughts, ideas and passions could be an instrument for the world.

If the 20th century was marked by the physician-as-silo, the 21st century will be marked by the dissolution of barriers and the emergence of new ways of collaboration and thinking. This will be a generation marked by information and networks. The institutions that existed to organize us will give way to social structures compatible with the way we communicate. Tools for sharing and drawing from collective intelligence will capture our restrained wisdom. And I suspect that we'll see the most amazing things emerge.

This post by Bryan Vartabedian, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post, medical education

Medical malpractice reform losing physician support

With regard to physicians' support for medical malpractice reform, "The times they are a changin'." These iconic words of Bob Dylan, who has now reached his eighth decade of life, apply to the medical liability crisis that traditionally has been a unifying issue for physicians.

The New York Times reported that physicians in Maine are going soft on this issue, but I suspect this conversion is not limited to the Pine Tree State. Heretofore, it was assumed that physicians as a group loathed the medical malpractice system and demanded tort reform. The system, we argued, was unfair, arbitrary and expensive. It missed most cases of true medical negligence. It lit the fuse that exploded the practice of defensive medicine. Rising premiums drove good doctors out of town or out of practice.

What happened? The medical malpractice system is as unfair as ever. Tort reform proposals are still regarded as experimental by the reigning Democrats in Congress and in the White House. The reason that this issue has slipped in priority for physicians is because our jobs have changed. Private practice is drying up across the country for the same reasons that family owned hardware and appliance stores are vanishing.

Look what has happened to independent bookstores? If you want to find one in your neighborhood, you may need to hire a private investigator. Private physician offices are being squeezed out by surrounding medical institutions that, using Ross Perot's famous phrase uttered in the 1992 presidential campaign, have created a "giant sucking sound" as it vacuums up patients from private doctors' waiting rooms.

This is only half of the story. Sure, the medical behemoths that employ doctors have cut deeply into private physicians' patient bases. But, increasingly, physicians are joining these enterprises willingly becoming employees of hospitals and large multispecialty clinics.

Understandably, these physicians who are entering their careers do not want the lifestyles of their predecessors. They want time off and a decent family life. They want hospitalists to admit their office patients who need in-patient care. They don't want to spend hours of uncompensated time each week on paperwork that doesn't help patients or improve their medical skills. They don't want the stress of making payroll, hustling for patients or engaging in the fun pastime of trying to convince insurance companies to pay them what they are owed. You get the idea here. They are shifting to a shift work culture, and I certainly understand why.

Can these doctors still get sued? They can, and they will. But, they are not paying their own medical malpractice premiums. Some of the larger medical institutions that employ them are self-insured. Since these physicians are not paying the bill--or any bills--they don't have the same stake in the game that we private practitioners do. Medical malpractice reform is still on their radar screen, but the blips occur at a higher orbit. They are focused on other issues.

What this means that one of tort reform's most unified and vocal constituencies will lose interest in the medical liability issue. The crop of physicians entering the profession in the next decade just won't view medical malpractice reform as a religion. Of course, they will reel when they are unfairly sued, as we do, but it won't be an issue that commands much of their attention in between lawsuits.

Folk music is prophetic. Where have all the doctors gone? Long time past seen. Will medical malpractice reform ever really happen or will it continue to be just blowin' in the wind?

This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Labels: career choices, defensive medicine, guest post, health care cost, health care reform, malpractice, MD Whistleblower, Michael Kirsch

Electronic health records, quality and safety take the fore at Pritzker IHI open school

A classroom at the University of Chicago's Pritzker School of Medicine was packed earlier this month with both medical students and students in the Graduate Program in Health Administration and Policy (GPHAP) interested in learning more about the IHI and quality improvement. Dr. Chad Whelan, a hospitalist and institutional leader on quality improvement, facilitated an open discussion about some of the challenges in using electronic health records to improve quality of care and encourage physicians to practice more evidence-based medicine.

Some of the topics covered included the unintended consequences of using electronic records, the benefits of an electronic record from an administrative standpoint, and issues surrounding the quality of documentation. The meeting was organized by students in Pritzker's Quality and Safety Track with guidance from Laura Botwinick, Director of GPHAP. During a lively and interactive question and answer session, here are just a few of the questions that were raised by students and the discussion that ensued.

How interoperable are the record systems? Why aren't we using one single interoperable system?
While interoperability is a focus of "meaningful use" that is part of American Recovery and Reinvestment Act of 2009, electronic health records industry is also a marketplace with vendors competing for market share. Because of that, interoperability may not have been achieved earlier.

For larger healthcare systems such as the VA, the implementation of CPRS represents an example of an interoperable system across many hospitals nationwide. Since academic medical centers often have several teaching hospital affiliates, physicians and trainees have to learn to work in several different systems, some of which may not even talk to each other. While many urban medical centers have adopted electronic health records, a recent study demonstrated only 17% of hospitals capital investments.

What are the reasons behind the findings in the literature that mortality and errors sometimes increase when an EHR is installed?
Medicine is a complex system and sometimes changing one thing without changing another will yield unexpected outcomes. Furthermore, if bad processes are automated, errors can happen much more quickly and systematically if they were being made in the first place. That is why it is important to use QI tools to improve systems before an EHR is laid over them.

For example, during a QI intervention for pressure ulcers, the implementation of EHR for nursing documentation actually led to a decrease in the physician recording of pressure ulcers since they did not know where to access nursing notes.

How much training do practicing physicians get when an EHR is deployed?
Training is definitely part of the EHR implementation strategy. One commonly used approach is to actively train early adopters who can champion it for the late adapters and laggards. At our hospital, that training included several hours of classroom time plus watching online video trainings at home with practice tutorials. However, as the faculty and others present agreed, the learning curve is steep and learning is an ongoing process. Anecdotally, there is often "reverse mentoring" with many of the residents who learn on the job are able to teach the attendings tricks of the trade.

What can be done to avoid the cut and paste problems that have emerged?
Interestingly, hospitals often have the choice whether to disable cut and paste or keep it active. By disabling it however, the ability of EHRs to make doctors more efficient is sacrificed. However, enabling cut and paste creates the risk that the information is out of date or inaccurate.

While many egregious examples have been described in the literature, there are some novel experiments being tried around the country include trying to use different colors for pasted information or creating patient records like wikis so multiple people are updating. In a handoff curriculum for residents, we do highlight avoiding CoPaGA syndrome (Copy and Paste Gone Amok) by highlighting that it is allowed to cut and paste but their responsibility is to cut, paste and update.

Are medical students getting trained on electronic health records?
Most learning at present is orientation to a specific system and on-the-job training. Principles of effective practice with EHR need to be translated into medical education as it is an important core skill that all medical graduates will need. While medical informatics is covered by in some form in many medical schools, recent debates highlight that more robust teaching on electronic health records needs to evolve and expand. Moreover, the EHR can be used to actually advance medical education by providing a record of what types of patients a resident sees and assist in performance evaluation of patient care.

--Anthony Aspesi, MS2 (with Laura Botwinick and Vineet Arora)

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

Labels: electronic medical records, FutureDocs, guest post, medical education, patient safety, quality improvement, residency training, Vineet Arora

Medical Skepticism, vol. 5

Tip of the cap to the St. Louis Cardinals for their inspired comeback and World Series victory.

I offer an even bigger hat tip to famous Alabama orthopedic surgeon Dr. James Andrews for his robust medical skepticism.

Those of you that are sports fans have no doubt heard of Dr. Andrews. He is to pitchers' elbows, shoulders and knees what Andy Warhol was to Campbell's Soup.

The New York Times trendspotted the following big medical news: Doctors order too many MRIs.

Shocker, right?

You may have read something like this before; here the difference is that it's the folks most likely to benefit from the superfluous imaging tests that are decrying their overuse.

Orthopedic surgeons generally only earn income when they perform operations. So it comes as big news when the best and the brightest of the bunch tell us we don't need the tests that lead them to do operations.

In fact, the technology in the MRI is so good that it defies our understanding of what to actually do with the information it provides.

Here are some key points from the Times article that will save you the trouble of clicking over there:
1) The details in an MRI are such that a radiologist almost never interprets a study as "normal."
2) The irregularities that make an MRI "abnormal" seldom correlate to physical symptoms (more on this below).
3) As an example: when a healthy runner goes for a jog, she'll have evidence of "abnormal" fluid noted in her knee capsule on an MRI scan immediately afterward. But there is no injury.
Dr. Andrews, in a gutsy move, obtained MRIs on the shoulders of 31 professional baseball pitchers. To quote the article: "The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90% of them and abnormal rotator cuff tendons in 87%. "If you want an excuse to operate on a pitcher's throwing shoulder, just get an MRI.," Dr. Andrews says."

In training, I was taught about a study in which 100 consecutive healthy volunteers received MRIs of their low back. Even though none of the subjects had symptomatic back pain, 33 of them had abnormalities on their MRIs, things like disc "herniations" and "protrusions."

What do we do with that information? Should we offer the volunteers surgery that they don't need?

Dr. Andrews and his orthopedic colleagues are asking themselves the same questions about their patient-athletes.

A take home point: don't demand an MRI from your doctor if you have a musculoskeletal athletic injury. Time itself heals many wounds.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

Labels: diagnosis, Glass Hospital, guest post, John Schumann, radiology

5 steps ensure staff aren't becoming sleep fatigued

Health care facilities should take five steps to ensure staff aren't becoming sleep fatigued, according to a Sentinel Event Alert from The Joint Commission.

Shift length and work schedules impact job performance, and in health care, that means patient safety, the alert stated. A study of 393 nurses over more than 5,300 shifts showed that nurses who work shifts of 12.5 hours or longer are three times more likely to make an error in patient care.

Furthermore, residents who work traditional schedules with recurrent 24-hour shifts:
--make 36 percent more serious preventable adverse events than individuals who work fewer than 16 consecutive hours,
--make five times as many serious diagnostic errors,
--have twice as many on-the-job attentional failures at night,
--experience 61% more needlestick and other sharps injuries after their 20th consecutive hour of work,
--experience a 1.5 to 2 standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks, and
--make 300% more fatigue-related preventable adverse events that led to a patient’s death.

The Joint Commission recommended five specific steps to take:
1. Assess fatigue-related risks, including those for off-shift hours and consecutive shift work.
2. Assess hand-off processes and procedures to ensure that they adequately protect patients against mistakes due to fatigue.
3. Invite staff input into designing work schedules to minimize the potential for fatigue.
4. Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue. These strategies can include: engaging in conversations with others (not just listening and nodding); doing something that involves physical action (even if it is just stretching); avoiding caffeine when already alert or when nearing bedtime); taking short naps (less than 45 minutes).
5. Educate staff about sleep hygiene and the effects of fatigue on patient safety.

"We have a culture of working long hours, and the impact of fatigue has not been a part of our consciousness," said one physician, a sleep expert and author of several research studies on sleep's effects on providers and patient safety, in the report. "Most are unaware of sleep and circadian biology and the degree that it affects performance. And, most do not realize how much research supports the need to make changes."

Labels: nursing, patient safety, residency training, staffing, work-hour limits

Life at Grady: Redemption

The following post, by Kimberly Manning, MD, FACP, is adapted with permission from
her blog, Reflections of a Grady Doctor. All identifying information has been changed to protect privacy.

The story was straightforward enough. This forty-something year-old gentleman had been admitted to our team for chest pain. It started as a "twinge" and then evolved to more of a pressure. He was smart enough to not ignore any of it or do what many forty-somethings with chest discomfort often do--chalk it up to indigestion or acid reflux.

"My father died from a heart attack in his forties," he said matter-of-factly as I stood on his right side that morning on rounds. "And I think his brother before him did, too."

"Wow," I responded while nodding my head.

He pushed his hands down beside him and scooted upward in bed. I saw his biceps bulge when he did that, and looked at his date of birth to confirm his age again. Other than the deeply embedded crows' feet exploding from the corners of his eyes, he looked young for his age.

"Yeah. I'm not sure what either of them did about it, but the minute I felt something in my chest I came on in." He ran his fingers through his reddish-brown hair to push it off his face. It looked like some fairy had dusted Mr. O'Malley with freckles from head to toe. Even his lips were speckled with tiny brown spots.

"That was a smart thing to do," I affirmed with a smile. Mr. O'Malley looked up at me and returned the favor. I decided that I liked how his almost invisible strawberry blonde eyelashes framed his eyes. I'd never seen eyes like these. Some unusual shade that appeared baby blue one minute and greenish-gray the next.

And so, I did what I usually do. I recounted the story that I'd just been told by my team and inserted a few more questions of my own as the team stood close by listening. Two interns, two medical students and a senior resident all focused on Mr. O'Malley and his words.

He was an excellent historian, so it was easy to create a fluid story board for his present illness. Chest pain that started at rest while watching television on his couch around 7 p.m. Had just eaten some pizza and washed it down with two Budweisers. That was about it. Nothing too crazy. "Matter of fact, it was Bud Light." We all chuckled at that clarification.

Beyond that concerning family history, the rest of the history wasn't too bad. A previous smoker, but not any more. Very active, even played full court basketball several times per week up until about three years ago.

"What made you stop shooting the hoops?" my resident chimed in from the foot of the bed.

He glanced down for a moment as if thinking for a split second before answering that question. "Oh. . .uhh. . I was incarcerated at the time. I spent twenty years in federal penitentiary."

The room fell awkwardly silent. If you listened hard enough, you could hear the collective sounds of our consciences' reactions.

Twenty years? Daaaaaamn.

(Click "more" below to keep reading.)

He closed his eyes and raised his eyebrows while nodding. Freckles were on his eyelids, too. He cleared his throat to break up the tension and said, "Yeah, so that was kind of time consuming." One or two nervous laughs tumbled out of our mouths. He curled his speckled lips and added in the students' direction, "Yeah, and don't believe what they tell you. I'd recommend medical school over the Pen. Definitely." This time we all laughed together, appreciating his willingness to ease things up.

My resident spoke up to keep us on task. "Well, Mr. O'Malley, the good news is that it doesn't look like you had a heart attack. We looked at your EKG and your lab tests and it all looks good."

"That's good to hear."

"Sir, have you had any more chest pain since you've been here?" I asked.

"No, ma'am," Mr. O'Malley replied.

"Okay," I continued. "Right now, the game plan is to get you a stress test today and if that looks good, we should be able to discharge you this afternoon." He nodded and held out a thumbs up. That's when I noticed the tattoo on the side of his right thumb. Some sort of intricate symbol that I couldn't quite figure out. He caught me noticing it and a strange expression came across his face that told me not to ask about it.

I reached for his right hand with mine and felt his pulse with the other. For some reason I intentionally covered that unexplained tattoo with my thumb as I held his hand. I feel certain that something in those chameleon-colored eyes washed over with appreciation for that gesture.

"Well, I guess it would be good if I examined you, now wouldn't it?" I teased. "Here I am giving you the plan and all I've done is arm wrestle with you!" The team sounded like a laugh track behind me, but Mr. O didn't laugh at all. In fact, he looked worried. Unusually worried.

What the heck was going on?

I paused for a moment and tried to figure it out. I had no idea. Scared I'd find something they didn't? Fearful that my need to examine him meant that I was hiding something that hadn't yet been discussed? I couldn't tell.

"Sir, you know, in teaching hospitals we always put our heads together about every patient. I don't want you thinking that me double checking the physical means something bad." I decided to make that disclaimer, hoping this might explain the terrified look on his face.

"Umm. . . noo. . .that's cool. I mean, I realize that." His eyes darted from person to person and then back at me. I could tell that he was willing himself to be calm, but it wasn't working. His face became white as the sheet over his lap and his un-inked hand moved protectively over his abdomen.

What the hell? I couldn't figure out what was wrong. Was he angry? Had I offended him? What? What was this initially cool dude so freaked out about?

I looked into his pleading eyes and tried to communicate with them. He was trying hard to give me a message and I wasn't getting it. "You okay, sir?" I finally asked. When he nodded in the affirmative, I reached for the top of his hospital gown and prepared to unfasten the buttons across the shoulder. I noticed his forearm tensing up over his abdomen as I unsnapped the last snap and prepared to expose his chest. Carefully, I began to fold down the corner, but then froze for a moment.

His face had now melted into a pool of dread and shame. I didn't know what the hell that was about but I knew for sure that for some reason he didn't want me to see his chest. And so, I did something I almost never do. I reconnected the gown and placed my stethoscope directly on top of his gown, fully ignoring one of my biggest pet peeves--listening to people through clothing.

I auscultated his covered heart, knowing that my medical students were all giving me the hairy eyeball and secretly preparing to call me a hypocrite for breaking my own rule: "S.O.S! That means 'SCOPES ON SKIN!"

Next, I asked him to sit up for the lung exam. The gown gaped open in the untied areas exposing little pockets of skin that I could see from first glance were also covered with tattoos. I slid my stethoscope behind his gown--this time listening directly on his skin--and asked him to take a deep breath.

Inhale. . . exhale.

Methodically, I moved my scope off of that space and inched downward. That flick of my wrist unraveled the tie and the gown fell wide open revealing his entire back. Covered with more freckles and tattoos indeed.

He immediately stopped midbreath and so did I.

Daaaaaaaaamn.

I almost said that out loud because finally I understood his trepidation. And got that message loud and clear.

Fortunately I was the only one back there to see what that gown was hiding. His entire back had become a canvas decorated with a giant tapestry of absolutely horrific black swastikas and black letters. I couldn't make out any of the letters--something on it was in German? I didn't know. . but those swastikas. . .those swastikas were unmistakable. And terrifying to see that up close.

I was so stunned that I didn't know what to do. So those three seconds of him midbreath and me frozen with my stethoscope trembling on his back felt like an eternity. That's when I decided to stick to the basics.

"And another deep breath," I continued. And he gave me breaths as long as I requested them.

After that, I simply tied up the back of his gown as normally as I could.

When I finished the exam, I faced him again and locked eyes with him. I knew for sure that what I saw in those eyes looked apologetic and ashamed. So I grabbed that right hand again and covered that little thumb ink once more, now knowing that it too represented something that probably wasn't so loving toward me, my Asian resident, or my Jewish medical student and intern. "Everything checks out fine."

He squeezed down on my hand, his nail beds flushing bright pink. "Thanks." That was all he said with his mouth. But that hand shake and those chameleon-eyes said a lot more.

Later that afternoon, I came back to see him prior to his discharge. The stress test was pristine and he was good to go. I started off all business, talking about his follow-up plans and seeing if he had any questions. He obliged me, but we both knew we had some loose ends to tie up.

"Twenty years is a long time," I finally said, breaking the ice.

"Yeah," he quietly responded while looking down. "I was only nineteen when I got there. And. . .that world. . . . that world is so twisted up. You start thinking. . . and believing things . . . .crazy things. . .that. . . .just. . .I mean. . .yeah. . .and then you come out in the real world and you . . . yeah."

"You got those in the pen?" I called out the elephant in the room. Swastika tattoos weren't something I saw every day in real life. And I won't even front--having my stethoscope on top of one was scary as hell.

"Yep. In a gang. Like one of these gangs that becomes the only family you know, to survive in a place like that. But when I got like 35 I started realizing that I didn't hate nobody like that. Like in my heart I knew that wasn't true, you know?"

"And here comes this black lady doctor whipping your gown open in front of a group of onlookers."

"Man. I was so glad you didn't. You just don't know. I feel so ashamed of all this. Then when I saw you and saw that you was a black person? Man."

"I hear you. So the chest ink is worse than the back?" I asked incredulously.

He nodded. "If you can believe that. And I'm telling you. You don't even want to see that, either. You really don't."

I decided to take his word for it. "You could probably get them all covered up, you know. Or removed."

"I know. It just costs a whole lot and I don't have a lot of extra money like that. Plus not everyone is hot to hire an ex-convict, you know."

Point taken.

"What's the thumb tatt?" I at least wanted to know about that.

"Gang sign. But anybody who's done hard time would know what it is if they saw it, though. Soon as I get some money, I'm covering this one up first--'cause it's on my hand. Good thing most folks haven't done hard time or else I'd really be in trouble."

"You could rock a Michael Jackson glove. . . .you know. . .cover it up with a little sequined glove action until you can get it removed." I smiled as goofy as possible until he laughed out loud. That was all the nudge I needed to do a few MJ moves for him, including a leg kick.

Mr. O shook his head. "Doc, you one funny lady."

"Thank you very muuuuch, I'll be here all month!" I could tell he appreciated my lightness. And while there's nothing light about a swastika, I guess I just wanted him to know that we were cool and that I believed in redemption.

His face grew serious. "But for real, you got some good instincts, too. Thanks for paying attention."

"Thanks for trying to communicate with me," I responded. I snapped my finger and added, "Hey--what color are your eyes, Mr. O?"

"My grandma always said they was like a chameleon. Depend on where I am and what I'm doing."

"Gotcha." I looked at my billing card, circled "discharge" and prepared to leave.

"Hey, doc?" he said as I started toward the door. I stopped and raised my eyebrows. "You know. . . .like. . . I don't hate you, right?"

I gave him the most high-beam smile I could. With a happy nod of my head I replied, "Good, sir. Because I don't hate you, either."

I hit him with one more MJ move complete with a point and headed off to see my next patient.

Medicare ramps up rationing of cardiac and orthopedic care

With the announcement that the Center for Medicare and Medicaid Services (CMS) will begin auditing 100% of expensive cardiovascular and orthopedic procedures in certain states earlier this week, we see their final transformation from the beneficent health care funding bosom for seniors to health care rationer:

"The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. Shares in both industries fell with Tenet Healthcare Corp., the Dallas-based hospital operator, plunging 11% to $4.18, the most among Standard & Poor's 500 stocks. Medtronic Inc., the largest U.S. maker of heart devices, dropped 6% to $34.61.

The program means hospitals won't receive payment for stays that involve cardiac care or orthopedic treatment until auditors have examined the patient records and confirmed that the care was appropriate, Jerold Saef, the reimbursement chair for the Florida chapter of the American College of Cardiology, wrote in a Nov. 21 letter to members. The review process is expected to take 30 days to 60 days, beginning January 1, Saef said."

This is not at all unexpected. In fact, in our field of cardiac electrophysiology, we have known this day would be coming; our expensive, life-saving gadgets and gizmos are easy targets upon which the government can cut its rationing teeth. And so as it will go for us at first, and then for many other areas of health care.

But the government has no idea how to do this, really. They don't have the data, the cerebral wattage, acceptable information systems, nor manpower. So, the government will grow further to offset its shortcomings in order to assure they can "save money" for our health care system.

But CMS, like the U.S. Post Office, has a dirty little secret: they don't pay very well. To offset their low pay, they have to offer some pretty nice benefits to attract their best and brightest. And because the government is now going to bite off trying to manage an entire country's medical procedure rationing during a limited eight-hour government workday, they are going to be flooded with calls, many of which will be frustrated, angry calls that have been on hold a very, very long time.

And so they'll hire more people to improve services.

And pretty soon it will dawn on them: this is expensive to do. It will just be a matter of time when, like the Post Office that was affected by their inability to keep up with pension and health care costs, they'll surrender and turn over their efforts to private enterprise.

That's because health care is local. Health care is complicated and needs lots of data, systems, and capable facile people to make decisions on data the government wants but knows it doesn't have. (Remember when the Department of Justice had to "consult" with the Heart Rhythm Society to "understand" defibrillator implant practices by tapping into their NCDR database?) Further, because the government moves slowly, can print money when it runs short, and must work through politics, government rarely works under budget. (In fact, when money runs out in government, they just shut down – not a great idea when working in health care.)

Of course the insurers don't want this. They already know it's too damn expensive to take on the risk of our paying for the health care of our aging seniors. (They were one of the main proponents of health care reform, remember?) So the government will have to have their back somehow. (Those details still have to be worked out, but it'll happen because politically, it must).

And the final transformation of our health care system of the future will be complete.

Amen.

This post by Westby Fisher, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post, health care cost, health care reform

Doctors struggle to interpret advance directives

Struggling with the meaning of life is one thing. Struggling with the meaning of end-of-life directives shouldn't be.

Physicians misidentify living wills as do-not-resuscitate (DNR) designations and DNR orders as end-of-life care directives, concluded a study. Adding code status designations to a standard advanced directive can ensure that patients receive or does not receive the care they want.

The study, "TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders," appeared in the Dec. 5 issue of The Journal of Emergency Medicine.

Researchers conducted an Internet survey of general surgery, and family, internal, and emergency medicine residencies. Program directors were asked to forward survey solicitations to residents and attending faculty. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention.

Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded over 18 months. At baseline, 22% denoted "full code" as the code status for a typical living will, and 36% correctly equated "full care" with a code status DNR. Adding clinical context improved correct responses by 21%, and specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12% to 17% by adding code status such as "Full Code" or "Hospice Care," but were worsened 22% by adding the code status "DNR."

The authors wrote, "It is clear from the data that misunderstanding pervades medical specialties and is not resolved by the current instructional curricula involved advanced directives training and end-of-life decision-making."

Labels: end of life, palliative care

Large hospital systems are driving up health care costs

The primary stakeholders in the health care system are patients and physicians. Without patients or physicians there would not be a health care system.

Patients should be the drivers of the health care system. They are not. The primary drivers are the government and the health care insurance companies.

Hospital systems play the next largest role in driving up the costs of the health care system. Large hospital systems are constantly playing a game of chicken with the government and the health care care insurance industry.

Somehow, large hospital systems have been able to stay under the radar. They have been able to avoid the responsibility of the rising costs of health care.

Large hospital systems and large hospital chains know that insurers need them to service their network of patients. The health care insurance companies know that the hospital systems can hold them hostage to increased reimbursement.

When a large hospital system demands an increase in reimbursement the health care insurance industry simply increases premiums.

An example is the increasing premiums and costs that resulted from Romneycare in Massachusetts. Romneycare's structure is one large driver of rising costs in Massachusetts.

Hospitals in Boston were extremely competitive before 1990.

The race in the late 1980s was to build the best hospital/physician network in town. The goal was to attract patients, overwhelm the competitors and get the best reimbursement from insurers.

In 1993 the model changed from a competitive model to a monopolistic model.

The merger between two eminent Harvard-affiliated hospitals, Massachusetts General Hospital and Brigham and Women's Hospital developed a hospital system (Partners) that would control the marketplace.

The two most prestigious hospitals in the state forced the health care insurance industry to increase their reimbursement for providing care. Meanwhile, the Tufts hospital system offered a lower reimbursement rate but patients wanted to go to Partners.

Partners Healthcare created a monopoly. It could deny access to the patients of any insurer who dared not accept whatever Partners wanted to charge.

"What patient would want to be on an insurance plan that didn't have access to the two most prestigious hospitals in Boston?"

"Partners' secret agreement in 2000 with Blue Cross Blue Shield of Massachusetts, in which Blue Cross would give Partners more money, in exchange for Partners' promise that they would demand the same rate increases from everyone else. The growth rate of individual insurance premiums in the state doubled."

Many executives at Blue Cross/ Blue Shield wanted to fight Partners' demands. However discretion was the better part of valor.

An executive of Blue Cross/Blue Shield said, "We are a successful business up against a hospital system that save people's lives. It's not a fair fight ..."

Many hospitals are merging throughout the country to take advantage of this market leverage and increase reimbursement from the health care insurer.

Hospital systems are frantically trying to buy primary care physicians' private practices to enjoy this leverage. The statistics claim that from 30% to 70% of practices have been bought by hospital systems.

The fiction is that medical schools are producing a different breed of physicians. The fiction is all the present day physicians want is a salary. I do not think this is true.

The barrier of entry to opening a private practice is cost. Physicians completing medical school have already incurred large debt.

The problem with being employed by hospital systems is the hospital system controls the overhead expenses. These expenses are inflated. Many salaried physicians do not realize the unfair overhead expenses because the expenses are opaque.

It takes a while for physicians in the system to figure out that they are not getting their fair share of the reimbursement for their productivity. At that point physicians start fighting with the hospital system. Some physicians quit en mass and open their own practice.

Partners' physicians figured it out. Partners is still intact but the physicians are now getting their fair share.

Physicians are starting to realize they have leverage over their hospital employee and that they must have control of their overhead.

The Department of Justice is opening an investigation of hospital systems engaged in anticompetitive behavior. It is also challenging mergers in various parts of the country. Hospital systems have offered the defense that mergers will lead to "more efficient and cost-effective care."

"But the long history of hospital mergers shows no evidence that consolidation leads to either. Indeed, according to FTC lawyer Matthew J. Reilly, the merged Toledo hospitals immediately went to work jacking up rates:"

"Soon after the acquisition was consummated," Mr. Reilly said, "ProMedica approached certain health plans to obtain higher reimbursement rates."

"The higher rates, he said, are typically passed on to consumers in the form of higher premiums, co-payments and other costs."

Businesses act in the pursuit of their vested interests. Government sets the rules and businesses seek to take advantage of those rules.

Somehow, secondary stakeholders must be controlled. It will take a consumer driven health care system to control it.

This post by Stanley Feld, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post, health care cost, health care reform, hospital costs

Patients may be satisfied, but providers aren't

Medicare is beginning to tie financial bonuses to hospital patient satisfaction scores. Although patient satisfaction is important, I've voiced concern in the past about giving hospitals a financial incentive to cater to patient surveys.

In a previous USA Today column, I wrote, "Already, more than 80% of doctors ... said patient pressure influenced their medical decisions. And in primary care, linking bonus pay to patient satisfaction could cause physicians to be more selective in who they see, subtly keeping patients who they know will score them well, and referring disagreeable ones to other providers."

In the New York Times, which examines the issue, there are a myriad of other unintended consequences, most concerning of which are the fact that hospital amenities influence patient satisfaction: "... hospitals are worried that assessments from patients ... can be influenced not just by the quality of their care, but also by amenities like single rooms, renovated units and tasty food ... "

NYU Medical Center, for instance, found that newer facilities improved patient satisfaction scores--even as the medical staff stayed the same: "When NYU moved its cardiology unit to a renovated floor in 2008, patient rankings shot up even though the procedures and employees were the same. NYU found that long waits at its elevators drove down its scores, so now it is building a new bank of elevators."

Rich hospitals are better positioned to take advantage of this, as they can incorporate such hotel-like luxuries and spend money to improve patient services.

Again, at NYU Medical Center, money is spent on touches that have little to do with improving patient care: "NYU is scrambling to find lots of little ways to please patients. Nurses in the emergency room are instructed to greet people at the door within 30 seconds. Several floors have started happy hours, providing chips and cookies for family members. The maternity ward has been experimenting with giving women cellphones so they can text their nurses. When new mothers leave, they are given cards signed by doctors and nurses."

I'm not saying the patient experience can't be improved. It certainly can, and should be a top priority for hospitals.

But are patient satisfaction surveys the right instrument to, in part, base hospital reimbursement on? As it stands, such surveys only incentivize hospitals to spend more money to build new luxurious new buildings, and provide superfluous amenities like patient happy hours.

At a time when our health system teeters on bankruptcy, with more than 50 million Americans uninsured, that doesn't sound like the best use of resources to me.

Kevin Pho, MD, ACP Member, is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

Labels: guest post, hospital leadership, KevinMD, patient satisfaction, payment reform

Opioid-related adverse events cost hospitals $1,000, add one day to stays

Opioid-related adverse events (ORAEs) are associated with more than a $1,000 increase in hospitalization costs and more than a day increase in length of hospital stay, reports a pharma-funded study.

A retrospective analysis applied a national database of patients from 381 U.S. hospitals identified adults who underwent common soft tissue and orthopedic surgical procedures and received opioids for postsurgical pain from September 2008 to August 2010. All opioids consumed were converted to morphine-equivalent doses. About 20% of surgical patients experienced an ORAE.

The data were presented in collaboration with Premier Research Services, which supplied the data, and funded by Pacira Pharmaceuticals, Inc., a manufacturer of postsurgical pain management products. These findings were presented during a poster session at the 2011 Midyear Clinical Meeting of the American Society of Health-Systems Pharmacists in New Orleans.

A researcher from the study said in a press release that the study highlights the value of a multimodal, opioid-sparing approach to postsurgical pain management.

A second poster from the meeting supported by the same drugmaker identified patients undergoing total abdominal hysterectomy in one of six hospitals from January 2007 to December 2010.

The 97 total abdominal hysterectomy patients with the longest lengths-of-stay, termed "outliers," were matched to a control group of patients. Medical records from both groups were reviewed for total opioid use, incidence of ORAEs and total cost of hospitalization. Total opioid consumption in the outlier group was more than double that of the control group (150 mg vs. 74 mg; P less than 0.01).

Respiratory ORAEs occurred 12 times more often in patients in the outlier group than in the control group (12% vs. 1%; P less than 0.01). Gastrointestinal ORAEs occurred more than twice as often (44% vs. 19%; P less than 0.01). Total hospitalization cost was more than $8,500 higher in the outlier group compared to the control group ($14,275 vs. $5,745).

Labels: pain management, patient safety

Medical board exams may be a bureaucratic waste of time

In 1994 I was thrilled to become certified by the American Board of Emergency Medicine. I had worked very hard. I studied and read, I practiced oral board scenarios and even took an oral board preparatory course. It was, I believed, the pinnacle of my medical education. Indeed, if you counted the ACT, the MCAT, the three-part board exams along the way and the in-service exams, it was my ultimate test, the one that I had been striving for throughout my higher education experience.

I am now disappointed to find that my certification was inadequate. In fact, all of us who worked so hard for our ABEM certification find ourselves facing ever more stringent rules to maintain that status. And it isn't only emergency medicine. All medical specialties are facing the same crunch. Our certifying bodies expect more, and more, and more.

And the attitude is all predicated on the subtle but obvious assumption that those of us in practice are not competent to maintain our own knowledge base, despite spending decades in education that we are not to be trusted. That we are not interested in learning. That we do not attempt to learn and that our practices are not, in fact, the endless learning experiences they actually are. They assume we need more supervision, despite demonstrating (by our continued practice) that we are willing to do hard work, in hard settings, and do the right thing.

Unfortunately, the rank and file is very unhappy. There is remarkable discontent, and considerable anger, among the lesser physicians. That is, the test takers, the physicians in practice subject to the new rules, the ones who have to add one more rule, one more activity, one more form, one more check to their already busy lives.

That discontent, that anger, that frustration on the part of practicing physicians is, in my opinion, very rational. It's a tough time in medicine. Our regulatory burden grows by leaps and bounds every year. We are watched and harassed, by CMS, by JCAHO, by our state medical boards, by our insurers, by our hospital staff offices and now, most painfully, by our own specialties.

Of course, all of it comes in the context of falling reimbursements, a federal government licking its lips for any spurious allegation of fraud and a system in which EMTALA forces physicians of all specialties to see patients for free, even as government insurance programs pay less than the over-head to see their patients (and fulfill the regulatory guidelines required for the privilege of doing so).

In light of all of this, I have to ask ABEM and every other board certifying body, a simple question:

"What are you people thinking?"

Here's the reality. Our certifying bodies should be our greatest, most passionate advocates. When the Institute of Medicine issued a report some years ago that said physicians were killing people on a scale consistent with the holocaust, ABEM should have looked at the data and refuted it. ABEM, and ABIM and all the others should have taken our fees, run out and found the best PR firm they could afford. "We stand by our physicians and we have serious questions with these research results and the way they are being interpreted." That would have been a good use of my dues. That would have merited high salaries for everyone in every board that stepped up for its members.

Instead, at every step, ABEM seems to argue that "the public" wants us to be watched more closely and tested more frequently. Except, I'm not confident that's true. The public never cares where you went to medical school. The public thinks most emergency physicians are interns hoping for a "real practice" someday. The public wants affordable, quality care. The public, in practical terms, doesn't know the difference between a physician, a PA and a nurse practitioner, and often calls all of them "doctor." The public, furthermore, tends to believe that mid-level providers are more attentive to their needs. (Despite their lack of board certification; shocking indeed!)

More poignantly, more ironically, our policy-makers and academics often say that public needs a European-style health-care system with better outcomes and lower costs. Whether that is ultimately true or not, the funny thing is that Canadian and European physicians don't have to do ongoing board-certification activities. Hmmm.

More irony: medical practice is supposed to be evidence-based. So where's the data that board certification makes a difference in patient outcomes? Maybe it does, maybe it doesn't. But even if it does, we'll need to break it down to see if ongoing certification matters, if repeat testing matters, who sponsored the study, etc. Our certifying bodies should be eager to see independent evaluations of the question. Or would that be a problem?

It might be a problem from a financial standpoint. Is ABEM, or ABP or ABS or the ABMS simply "too big to fail?" Do they employ too many people to cease to be relevant? Is there a financial imperative for them to continue doing what they do? With director salaries in the $200,000 to $800,000 range (depending on board), is there a potential hint of conflict of interest?

How is this different from the financial conflicts of big pharma? Their drugs help people, even if their techniques are shady. Is this an uncomfortable question for everyone to ask?

It's a time of changing paradigms in the world at large. Print books are succumbing to electronic ones. The Internet is an unfettered land of free expression, uncontrollable by government entities or hospital administrators. People text more and talk less.

It may be time for us to look critically at the entire concept of board certification. It may be time for alternate boards to emerge. It's certainly time for our boards to be our friends, our advocates, and thereby justify their cost. And it's likely the future will not look like the present, when it comes to the way we certify physicians. In an era of impending physician shortages and fewer reasons to enter medicine as a whole, I hope that we can remove some obstacles and stand up for one another.

That's a change I can get behind. And that's a change that would make me much happier to write that check to ABEM when the time comes.

This post by Edwin Leap, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: guest post, maintenance of certification, medical education

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Contact ACP Hospitalist

Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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Related ACP Resources:

ACP Hospitalist

Wednesday, December 28, 2011

Life at Grady: Mentors

Thursday, December 22, 2011

Nearly 9 in 10 doctors stressed on any given day

Wednesday, December 21, 2011

Holiday decoration-related ER visits: Are these statistics sending the wrong message?

Life at Grady: Slip Slidin' Away

Tuesday, December 20, 2011

Using GoAnimate to create case scenarios

5 steps for flu prevention should include mandates for health care workers

Monday, December 19, 2011

Do doctors feel that they need permission to share ideas?

Medical malpractice reform losing physician support

Electronic health records, quality and safety take the fore at Pritzker IHI open school

Thursday, December 15, 2011

Medical Skepticism, vol. 5

5 steps ensure staff aren't becoming sleep fatigued

Wednesday, December 14, 2011

Life at Grady: Redemption

Tuesday, December 13, 2011

Medicare ramps up rationing of cardiac and orthopedic care

Doctors struggle to interpret advance directives

Monday, December 12, 2011

Large hospital systems are driving up health care costs

Patients may be satisfied, but providers aren't

Opioid-related adverse events cost hospitals $1,000, add one day to stays

Thursday, December 8, 2011

Medical board exams may be a bureaucratic waste of time

Contact ACP Hospitalist

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