Wednesday, February 29, 2012

Life at Grady: Yes, we can

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.

I saw this patient today who was dying. Not dying in the immediate sense where people were running and shouting and drawing up meds and charging up paddles. No, not like that.

But still, he was dying.

Mr. Ward had been seen at another hospital with what he described as a "sour stomach" and "feeling weak." A few tablespoons of baking soda and a little milk of magnesia hadn't helped. Two CT scans and one biopsy later that pain in his stomach proved to be something of much greater concern than the "ind'gestion" he'd initially told them he thought it to be. This was cancer.

Cancer not only in his abdominal cavity but also deep down in his bones. And this kind of cancer is not the kind that can be wrestled to the floor by chemo or pinned to the mat by radiation. At best, those things could keep certain symptoms at bay but, short of a miracle, Mr. Ward was dying.

At this visit, he was joined by his daughter. She looked devastated by the news and he was quiet and peaceful. With glistening eyes, she asked questions about her father's condition. And with each answer, she said, "Thank you, doctor." Even though her mouth was appreciative, her morose expression made it clear that she would rather not hear what we were saying about her father.

But not him. He was as cool as a fan.

(Click "more" below to continue reading.)

"What all y'all got to do to get this on behind me?" he asked matter-of-factly.

"Well," I started, "the best place for us to focus is on how you feel. How do you feel?"

"I feel like I want to get this on behind me. That's how I feel."

His daughter looked at me carefully and then spoke before I could answer. "Daddy, your body is very sick. It might not be that simple."

"What you talking about? Tha's why I'm at the doctor!"

"But Daddy you. . .you have cancer going through your body."

"There you go! Don't be sayin' nothin' to me 'bout that ol' cancer, neither. Look like the minute somebody go and start calling something cancer it jest get worser." Then he turned toward me. "Jest tell me what all y'all need to do and I'll be there."

"Are you in pain, sir?" I asked.

"I have a little bit of pain on my side. Other than that, I'm alright."

"Okay," I answered. "We can help with that pain, okay?"

"That sound good to me," he replied. He rubbed his thumb across the front of the soiled baseball cap resting in his lap. That hat looked like one he'd worn every single day for quite some time. In red, white, and blue it had big letters sewn into the front: OBAMA.

I smiled at him and thought for a moment about that hat and the fact that he'd lived to see Mr. Obama take office. Something about that offered me a bit of comfort in the face of all this bad news. I paused, thinking carefully what to say next.

In the silence, his daughter let out a large sigh and straightened up in her chair. Instinctively, I reached out for her hand. She let me.

Something about that gesture struck a chord with Mr. Ward.

"They got a medicine for this, right? I mean, y'all got something that can knock this on out, right?"

"Mr. Ward, sir? We have things to help you feel better. We don't have something to completely make it go away."

Now his daughter's eyes were brimming with tears. He looked from side to side--first at her, then at me, over to her, and back to me.

"Then what do that mean?"

"Every person is different, Mr. Ward. Most people who have this kind of cancer. . .um. . .they. . " Something about the way he was staring at my mouth made me feel nervous about my choice of words. I hated the thought of robbing him of his peace. But I needed to be honest.

Sometimes the easier thing to do is punt the hard questions like this over to the cancer specialists. To simply give the most vanilla answer you can and leave the slow singing and flower-bringing to them. And in many instances, when things aren't exactly clear, that's acceptable. But his query was not about five year survival or percentages. It was a simple question to which I knew an answer.

"Mr. Ward, sir?" I exhaled and tried again. "This kind of . . .um. . cancer. . is a kind that works really hard to shorten your life. Even when we fight against it, this particular kind flicks us away like gnats. So a good thing to do is to make sure you feel okay, you know? Like make sure you're not in pain and feeling all bad."

"And jest die?"

I swallowed hard and looked back at his daughter. She decided to help me out. "Daddy, it's all up in your bones."

"Sir, I. . . " The minute I started talking he swung his head back from his daughter to me. Something about the look on his face told me to stop talking.

"What you need to know and you need to know is that that ol' tumor ain't the only thing in these bones, you hear me?" He pointed from side to side at each of us then patted his chest. "Like Jeremiah say, 'It's like a fire shut up in my bones!' I got faith. Even if y'all don't. I got faith in the Lawd and what He can do."

His daughter looked down at her hands like a child. Even though she was easily in her forties, she quickly regressed when her father spoke firmly. Finally, in a tiny voice she pleaded, "Daddy, you want His will. That's what you want. That don't mean I don't have faith, Daddy. It don't."

"Well, you HAVE not 'cawse you ASK not! See, that's the problem with y'all young folks. Yo' faith ain't even like a mustard seed!" He held his two fingers up to demonstrate the minuscule scale of that metaphoric mustard seed. Then Mr. Ward shook his head and then looked back at me. "So when I'm 'posed to see the cancer doctors?"

"Um, you see the main cancer doctor or oncologist on Monday and you have the appointment with the Palliative Care doctors tomorrow."

"What do 'palliate care' do?"

"They focus on your symptoms. Make sure that your pain is controlled and lots of other things."

"Is that the same thang as the hospice?" Mr. Ward asked with eyes narrowed.

"No, sir. It isn't." Which technically was true. At least, sorta kinda.

"Alright then." He slid his tattered Obama cap on top of his head and gave his arms an exaggerated fold. His daughter was staring at him still, her face filled with emotion. Mr. Ward did a bit of a double take and then rolled his eyes. "Come on, here, and finish up 'cawse both a y'all depressin' me!"

We wrapped up the visit and Mr. Ward and his daughter went on their way.

Throughout the day, I thought a lot about Mr. Ward and his take on his diagnosis. I let his words on faith (or even attitude depending on what you believe) marinate with me and wondered where the line should be drawn between that and reality. I still don't know the answer.

Sometimes I find the overly pragmatic patient even more disturbing. And I'm not sure why.

I guess I wrote about this encounter because it made me think about faith and attitude and myself. I say things to people that include "the facts" and have gotten into the habit of habitually buffering it with words like "This is only the information we have available to us medically. There are definitely times--depending upon what you believe--where it becomes clear that we don't have the final say on the outcome." And that always seems to be met with nodding heads and "Yes, Lords" especially at a place like Grady Hospital. Which always seems to make me feel better about what I'm saying.

But does it really matter how I feel about what I'm saying? My guess is somewhat--but it matters much more how the patient feels.

As far as Mr. Ward goes, that over-worn baseball cap with the 44th president's name embroidered across the front of it seemed to say what he wished I had:

"Yes, we can."

Labels: cancer, faith, Life at Grady

The new subspecialty of clinical informatics: Some (but not all) questions answered

Last fall, the American Board of Medical Specialties (ABMS) approved a medical subspecialty in clinical informatics. The approval of this subspecialty is a recognition of the critical professional role played by clinical informaticians.

As information is so critical to 21^st Century medicine, whether in the need for healthcare to be more accountable for its operations or in the coming complexity of clinical decision-making from the data "tsunami" due to advances in genomics and related areas, there will be increasing need for those who work at the interface of medicine and information systems.

Although administered by the American Board of Preventive Medicine (ABPM), the subspecialty will be available to all physicians who have a primary board certification, which is a first for medical subspecialties. The first offering of the examination will likely take place in late 2012 or early 2012 for those who meet the criteria for "grandfathering" of the training requirements.

In the long run, physicians wanting to subspecialize in clinical informatics will need to complete formal fellowship training. The motivation for physician certification in informatics is to recognize the growing stature and need for professional expertise of physicians who spend a significant amount of their time performing informatics-related duties. This includes not only the growing role of the Chief Medical Informatics Officer (CMIO), but other jobs where a physician draws on his or her expertise at the intersection of medicine and informatics.

A great deal of further information is available about this development. The American Medical Informatics Association (AMIA), which spearheaded the effort, has developed a subsite of its website devoted this effort. The site includes a background document, the original press release announcing the ABMS approval, a collection of frequently asked questions (FAQs), and an article by AMIA President Dr. Ted Shortliffe.

I report on this topic periodically in my own blog as well, and an audio report from the iHealthBeat website is also informative.

The "gold standard" for any type of certification of physicians is board certification. There are currently 24 specialty boards (e.g., internal medicine, family medicine, pediatrics, surgery, radiology, preventive medicine, etc.), most of which have subspecialty boards as well (e.g., cardiology, hematology/oncology, and general internal medicine in internal medicine). Some subspecialties, such as geriatrics and palliative medicine, are offered by more than one specialty board. This will be the model for the clinical informatics subspecialty, and in fact it will be offered by all 24 specialty boards.

A comprehensive overview of the rationale and plan for developing the clinical informatics subspecialty was published in early 2010 by Detmer et al.¹. This paper described the development of medical specialties and subspecialties generally and in the context of the new proposed subspecialty of clinical informatics. A more recent overview of the status board specialties was published last year and included mention of the proposed one for clinical informatics.² Papers published in 2009 laid out the details of the core curriculum ³ and training requirements ⁴ for the subspecialty.

The proposal to establish the clinical informatics subspecialty was developed by the American Medical Informatics Association (AMIA) and submitted to the ABMS in 2010. The lead board submitting the proposal was the American Board of Preventive Medicine (ABPM), which has since been joined by the American Board of Pathology. These two boards will be the administrative home for the subspecialty although as noted above, physicians of all primary specialties will be able to become certified.

Certification in clinical informatics will work like any other multi-board subspecialty. To become certified, a physician will need to meet certain training requirements and then pass a certification exam. In the early years (usually the first five years of a specialty's existence), those with a certain level of experience will be able to "grandfather" in on the training requirements in a "practice track" and certify by passing the exam only.

Those training after the initial practice track period will be required to complete some sort of fellowship in the specialty. The practice track requirements for clinical informatics will be determined after the ABMS approves the subspecialty and will likely apply to those with some defined level of time and depth of experience in clinical informatics settings.

Now that the ABMS proposal has been approved, the ABPM will begin development of a certification exam, which will likely become available in the fall of 2012 for those meeting the practice track requirements. The next step will be to define the requirements for clinical fellowships in clinical informatics and their accreditation by the Accreditation Committee for Graduate Medical Education (ACGME), which accredits residency and specialty fellowship training programs.

Even though the process for establishing the subspecialty is well-defined, a number of questions remain. One question is how many health care organizations and others will require their physician-informatician practitioners to be certified. Another question, very critical to academic informatics units, is what will be the role for formal didactic education, especially that offered by distance learning.

Programs such as ours at OHSU have been a popular vehicle for physicians and others to become informatics practitioners. The distance learning aspect has been especially valuable, as many clinicians enter informatics careers after they have established their clinical careers.

The graduate-level education approach has been validated by the strong uptake of these programs as well as the more recent funding for them though the Office of National Coordinator for Health Information Technology (ONC) University-Based Training (UBT) Program, including the program I direct at Oregon Health & Science University (OHSU).

I am hopeful that ACGME will adopt flexibility in the clinical informatics fellowship program educational programs, including possibly allowing organizations like OHSU to provide the coursework portion of the training requirements in settings where a large educational infrastructure is not available.

Although there are a number of details still forthcoming, this new development is an exciting one for the informatics field. AMIA is also developing other pathways for comparable certification not only for physicians who are not eligible for ABMS certification but also for informatics professionals of other backgrounds, both clinical and non-clinical. All of these will contribute to the critical role that informatics plays in the 21^st Century health care system.

References:
[1] Detmer, D., Munger, B., et al. (2010). Clinical informatics board certification: history, current status, and predicted impact on the medical informatics workforce. Applied Clinical Informatics, 1: 11-18.
[2] Cassel, C. and Reuben, D. (2011). Specialization, subspecialization, and subsubspecialization in internal medicine. N Engl Journ Med, 364: 1169-1173.
[3] Gardner, R., Overhage, J., et al. (2009). Core content for the subspecialty of clinical informatics. JAMA, 16: 153-157.
[4] Safran, C., Shabot, M., et al. (2009). ACGME program requirements for fellowship education in the subspecialty of clinical informatics. JAMIA, 16: 158-166.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, originally appeared at his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

Labels: Bill Hersh, career choices, guest post, informatics, Informatics Professor

Mindfulness in palliative care

Palliative care is an emotionally tough field for physicians and even more so for pediatricians. One coping mechanism is mindfulness, a way of remaining involved and aware of interacting with patients, yet detached just enough to allow for proper decision-making.

The goal of mindfulness is to act and be aware of acting at the same time, which creates a slight mental space that allows the physician to choose how he or she responds, instead of reacting, judging or lashing out.

This video comes from Stephen Liben, MD, a self-described "Buddh-ish" pediatric palliative care doctor, and an Associate Professor in the Faculty of Medicine of McGill University and Director of the Montreal Children's Hospital Pediatric Palliative Care Program. It comes via Canadian Virtual Hospice's YouTube channel.

Dr. Liben's take-home message is that mindfulness helps physicians cope with burnout and other side effects of becoming emotionally invested with patients. More learning mindfulness for internists is available here.

Labels: palliative care

Our broken system example #2: Fat cats

We have a cat. He's fat. His name is Zander, but we call him "Cat," "Kitty," "Loaf of Bread" (because that's what he looks like when he lies down and his fat spreads), lard butt, and "Fatso Catso." In the picture above he is sitting on a puzzle because ... well, because he's a cat.

There are two main reasons he is fat:
1. He always wants to eat.
2. We feed him too much.

Lest you think that we are bad cat servants (which is what you call people who own cats ... I mean, people who live in the cat's house), let me paint a picture. It's 6 a.m. and I go downstairs. The cat immediately meows continuously until I feed him. Then I go upstairs and do my normal morning routine. While I am up in the shower, my wife comes downstairs and is met by meowing and an empty bowl. We've learned that the cat's desperation for food is not indicative of his eating history, but my wife's natural reaction is to assume I did not feed the cat, and so give him a second bowl. He will do this every morning, sometimes tricking us into feeding him three times.

The same routine happens in the afternoon (we feed him at 6 p.m.). Around 3 o'clock, the cat begins his campaign of meow assaults on whomever he can bother. If you walk to the door of the garage, he rushes to it, knowing that behind that door is his food. Naturally, the only reason we would walk to the door is to feed him, right?

You get the picture. He is deceptive and is difficult (if not impossible) to satiate. We've gotten better at regulating his weight, but only at the cost of the persistent meowing which serenades 50% of our waking hours.

What does this have to do with our broken system? Just change the food to money, and then think of all of the people who profit off of health care.

The second broken thing in our system is the fat cat. A fat cat is a person, group of people, or company that gorges off of the money in our system. Not everyone making money in health care are fat cats, most are simply getting money they earned from providing goods or services. But there are a number of fat cats in health care who are being given all the food they meow for. Here are a few examples:

Drug companies. Why are drugs so expensive? Because they can be. If government and private insurers were not paying for most of the drug costs, who could afford $200/month for Lipitor? People wouldn't buy most medications if they had to pay full price; the full price is impossibly high. Even many generics are over $100 per month. Despite this fact, the prices continue to be high and drugs continue to sell. Why? Because someone else picks up the tab.

It's as if the auto industry charged $500,000 for a new car. Since nobody can afford this, the government mandates car insurance to cover most of the cost. This brings the cost down to $20,000 to $50,000 for car buyers. Or if bananas cost $100 per bunch, but food insurance brought the cost down to $4. If you sold cars or bananas, would you resist this model? Would you trade a $500,000 payment from the government for a $20,000 check from the consumer? No more than my cat would turn down the third bowl of cat food.

Hospitals. Stents 'R Us hospital in our town just built a large cardiology wing costing 600 gazillion dollars. They did this using money from a procedure that has not been shown to prolong life or save lives. Sure, stents make a lot of sense logically (opening a blockage is a good thing, one would think), but it is, as of now, an unproven thing. But the marble lobby and the spiral staircase bear witness to the fact that they are not only paid for, they are paid for quite handsomely. Eat up, kitty.

Ancillary services. Why does a CT scan in India cost a fraction of the cost in the U.S.? Are scanners more expensive in the country in which they are made? Are the companies that sell the CT scanners warmhearted toward the people of India? No, CT scans are expensive in the U.S. because they can be. Again, it's the fact that the third-party payers shield consumers from the exorbitant amounts charged that makes it reasonable to price CT scans out of the realm of affordability. So what do the payers do about these high costs? They pass them on to the taxpayers or raise the rates of the insurance policies. It doesn't hurt them to pay so much, so they just keep feeding the kitty.

Doctors. Yes, we doctors are not immune to eating the cat food. Some docs pile up the number of appointments, giving less time for care so they can make more money. We primary care docs are stuck with a decision between money and quality of care. It's a terrible decision to have to make, and many decide that money is the most important thing. Other primary care providers just order a lot of tests from their own labs or X-ray facilities. We did this for a while, and the seductiveness of the dollar sign was too much for us, and we got rid of our X-ray equipment.

Then there are the highly-paid specialists. A banker friend of mine recently told me about a specialist who was complaining about how horrible reimbursement is, and how bad medicine is now. Then he found out that this doctor earns over $750,000 per year. Why do docs see so many patients that they can't offer good care, and why do other docs feel entitled to incredibly large salaries? Because they can. Someone keeps filling the bowl.

I think that the biggest cause of this gluttony is the third-party payer system which hides the cost from the consumer and gets us all used to the idea of paying for all that cat food. How many people are getting rich off of medicine? How many professions wouldn't exist without this all-you-can-eat buffet of cat chow? How many companies are rewarding investors with huge profits because their devices or drugs are paid far above their cost of manufacture?

All of this money is thrown at care, and what does it get us? Does it get us better care? Does it get us longer lives? Does it get us happier patients, or satisfied doctors?

No, it just gets us a bunch of lard-butt kitties meowing for more to eat.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

Labels: guest post, health care cost, More Musings, Rob Lamberts

How medical students should spend their final free summer

The summer between first year and second year of medical school is sometimes referred to as the "last summer" since it is the last time students can travel or take off before they start the journey towards USMLE Step 1 and then their third year clerkships. With the angst building, first year medical students are actively deciding in the dead of winter what they will do over the summer.

One popular decision is to do research. This is not uncommon since residency programs are increasingly competitive and look for students who have a commitment to scholarly work. However, there are a plethora of other things students could do as well. As tonight is our "Intro to our Summer Research Program" for Pritzker medical students, I thought I would share some of the most common questions I get about the "Last Summer."

Should I do research in a competitive field? The answer here is to do substantive research that you are interested in with a "CAPE" mentor (Capable, Available, Project interests you, Easy to get along with). As my premed advisor once told me, "Mickey Mouse" research is not going to look good to anyone (no offense Mickey).

The key is to find something you are passionate about. After all, you have to tell this story on your interview trail of why you choose to do this and the answer "because I wanted to go into ortho" is not really that captivating to anyone (even to an orthopedic surgeon). Instead, if you do something you are passionate about, like community health work, you can always tie it back to your chosen field.

Most residency program directors don't expect you arrived in medical school with laser-like focus towards their field anyway and expect to hear some type of journey or a-ha moment that drew you to their field. Because competitive specialties are often reimbursed for clinical work and tend to be smaller departments, they depth of research opportunities may be more limited. But, don't forget that neuroscience research is relevant to neurosurgery. Any oncology research on head and neck cancer is still relevant for ear nose and throat doctors, and so forth.

The best research is often interdisciplinary and crosses department boundaries so you should not be afraid to, either. It's also important to remember that as a first year student, it's hard to even know if you will be competitive for radiation oncology or associated competitive specialties. You will need killer board scores, and great clinical grades. So, while you may think securing the research with the department chair will give you an extra edge, nothing and no one can make up for a poor performance on high stakes exams or clinical rotations. So, don't forget to study!
I want to go to country X? How can I get a global health rotation there? Well, certainly the urge to travel is strong in anyone (including me). But, you need to separate your travel bug from a genuine interest in global health. Most global health rotations are not a vacation, and may not be what you think of as "tourist" destination (despite the short-lived popularity of Off the Map).

Maybe your stars are aligned and your school or a nearby affiliate you know has a program near your hot spot of interest. Usually, however, it is not that easy and you should consider how strong your affinity is for a specific country or location versus your interest in getting the best global health experience possible. Global health programs that fund medical students are not easy to come by. So, if you are genuinely interested in global health, it is always better to go with an established program and mentor to get the most substantive experience even if it's not in the exact country you are interested in.

The other thing to remember is while this may be your last summer for a while; it is not your last vacation! You will have time to plan a vacation to your designated hot spot if you can't work it in this summer.

Do I have to do anything? The answer here is easy. No, you don't have to do anything per se with your time off. Many students find themselves on the hamster wheel of endless extracurricular activities. The real question is what is your goal? If it is to go home and see family and friends, there is nothing wrong with that! The key is to ensure that you are doing something with your time off that will make you feel ready to face the second year of medical school.

It is easy to forget that there is a lot of time to participate in extracurricular activities at various other points in your medical school career. The key is that if you will regret not spending time with your friends or family this summer, then you need to make time to do that.

What if I want to do everything because I don't want to close any doors? This is not an uncommon feeling for medical students. However, it's important to remember that your summer work is not choosing a specialty! There is essentially nothing you can do over the summer that will close a door. There may be some things that allow you to put your foot further into the doorway, but that does not mean another door will close. The only doors you close are the ones in your mind.

Most students decide on their specialty after their third year rotations and will often fine-tune their experiences in research in that area in the fourth year. Another thing to consider is to do research in a cross-cutting area like ethics that could apply to everything.

Sometimes the angst you may be feeling is about making a choice that is wrong for you. However, the truth is that as long as you are genuinely interested in the opportunity, you cannot make a wrong choice since it will be an easy story to tell no matter what you do. Since everyone is different, it is always good to get individualized advice from a faculty advisor at your school who can comment on your specific career and research goals.

Finally, no matter what you do with your last summer, don't forget to make sure you enjoy it!
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: FutureDocs, guest post, lifestyle, medical education, medical student, Vineet Arora

Meaningful use adoption sparse as CMS previews stage 2

Physicians adopting electronic health records (EHR) are still spurning meaning use criteria, two industry surveys showed, even as the government has released details on expanding the criteria.

Physicians in groups of 10 or more are more likely to have adopted EHRs, even while remaining unfamiliar with regulatory issues, meaningful use criteria, and ICD-10 requirements, for example, according to a survey by the Deloitte Center for Health Solutions.

The company surveyed 501 physicians online (acknowledging this might bias responses to technology users). Because practice size might significantly impact results, the initial respondents were resampled, and 307 responded.

Nearly two-thirds said use an EHR, more among large practices (78% of 10 or more practitioners, 68% of 2 to 9 practitioners, 54% of solo practitioners). Solo practitioners are also unlikely to have plans to implement them (45% vs. 15% of group practices).

While physicians largely agree that EHRs are valuable in improving quality (84%) and important to managing patient care (79%), more than six of 10 physicians state that EHR use has not improved diagnosis accuracy or treatment planning, the report said.

It continued that while two-thirds of physicians agree that HIT can improve quality of care in the long run, two-thirds also believe that "the hospital-physician relationship will suffer as physician privileges are put at risk to comply with hospital standards for meaningful use," the report states. "Nearly 90% of all physicians believe that hospitals are more advanced in HIT than their own offices; more than three-quarters of physicians view HIT as a reason to collaborate with hospitals."

Reasons for not adopting EHRs included upfront financial investment (66%), operational disruptions (54%), privacy concerns (22%), vendor selection challenges (15%), and lack of incentives (13%).

Another survey concluded that while 42% of health care providers in all settings use EHRs, 39% have no plans to implement stage 1 of meaningful use. IVANS, Inc., a national health information exchange, announced the results in a press release.

Of that 39% with no plans to implement meaningful use, 26% of them are providers in hospitals and private practices that are eligible for incentives for doing so.

According to the company, 33% of providers surveyed said budgetary concerns are their biggest challenges, while 21% cited technology requirements. The survey was conducted electronically among 700 health care providers from across the U.S.

In stark contrast, the Centers for Medicare and Medicaid Services (CMS) are moving ahead with stage 2, the agency announced yesterday.

CMS announced that In Stage 1, providers and hospitals must meet or qualify for an exclusion to all of the core objectives and 5 out of the 10 menu measures in order to qualify for an EHR incentive payment.

CMS proposes for stage 2 that providers must meet or qualify for an exclusion to 17 core objectives and 3 of 5 menu objectives. Hospitals must meet or qualify for an exclusion to 16 core objectives and 2 of 4 menu objectives.

Other requirements optional in stage 1 but required in stage 2 include:
--changes to the denominator of computerized provider order entry,
--changes to the age limitations for vital signs
--elimination of the "exchange of key clinical information" core objective from stage 1 in favor of a "transitions of care" core objective that requires electronic exchange of summary of care documents, and
--replacing "provide patients with an electronic copy of their health information" objective with a "view online, download and transmit" core objective.

Even though there's been limited adoption of stage 1, there are some easy ways to achieve meaningful use criteria using an EHR. And, Farzad Mostashari, MD, the government's national coordinator for health information technology, spoke specifically to his fellow internists how they can best serve their patients and take advantage of incentives.

And, AmericanEHR Partners, a collaboration that include the American College of Physicians, reported last year that at least one week of training correlated with improvement in the reported usability of advanced EHR features (e.g. checking patient formulary, importing medication lists, and medication reconciliation). The full report, "The Correlation of Training Duration With EHR Usability and Satisfaction: Implications For Meaningful Use," and a corresponding chart pack can be downloaded.

ACP also make meaningful use resources available on its website.

Labels: electronic medical records, meaningful use

Hospital staff worried about culture of reporting mistakes

Hospital staff fee like hospitals support patient safety, yet hold reporting mistakes against the staff, reports the Agency for Healthcare Research and Quality (AHRQ).

The agency reported the results of its "Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report."

In tallying specific responses to questions, staff responded in the negative (such as "disagree" or "strongly disagree") with statements that detailed nonpunitive responses to errors. Three questions included like their mistakes are held against them (50%), the person is being written up instead of the problem (46%), or staff worry that mistake are kept in their personnel files (35%).

Other areas included handoffs and transitions. Respondents reported (again, percentages reflect negative responses such as "disagree" or "strongly disagree") that things fall between the cracks when patients transfer across units (41%) or that information gets lost among shift changes (51%).

On the positive side, however, respondents agreed with statements that hospital management provides a work climate that promotes patient safety (81%) and that their actions show that safety is a priority (75%).

In comparison, office-based staffers reported in an AHRQ survey from 2010 that office processes were good at preventing mistakes (79%). In other questions, they responded in the negative (again, a response such as "disagree" or "strongly disagree") that mistakes happen more often than they should (70%), it's just by chance that more mistakes don't happen (74%) and getting more work done is more important than quality of care (73%).

The 2012 user comparative database report displays results from 1,128 hospitals and 567,703 hospital staff respondents. It was designed to assess hospital staff opinions about patient safety issues, medical errors, and event reporting. The survey includes 42 items that measure 12 areas of patient safety culture. AHRQ also conducts surveys for physician practices and nursing homes.

Labels: handoffs, medical errors, patient safety

Life at Grady: What would Hippocrates say?

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.

"Define 'in/out'."

That's what I asked Richard, the Grady parking security guard, about the newly designated parking spaces the first day I saw the sign. "MD IN/OUT PARKING"--right next to the "Board of Trustees" parking spaces on the ground level. Nice.

He shrugged his shoulders and then answered, "I guess it's like, 'Oh, let me run in and sign this chart' or 'Whoops, I forgot to get something from my office.'"

"But no firm rule?" I countered eyebrows raised.

"Naaaah, Dr. Manning," he said with a chuckle, "It's on an honor system. You doctors know all about honor, right?"

Call me silly but I am not sure this alleged honor system includes a clause about scoring an excellent ground level parking space in a ten-story parking structure. At least Hippocrates didn't mention it anywhere in his oath.

(Click "more" below to continue reading.)

The Monday IN/OUT dilemma

It all started with a doorknob rattle at 4 am. Zachary can't seem to get our bedroom door open, so he just rattles it until one of us leaps to his doorknob defense. My mommy senses kick in and my eyes almost always fling open the second he places the first foot on the floor. Still, I passively-aggressively lie there waiting to see if Harry will get up first. Rattle-rattle-rattle. Pause. Rattle-rattle-rattle. Each pause is punctuated with a baby-baritone "Mom-may. Mom-may. Mom-may." (The kid has the voice of a thirty-five-year-old man.)

I looked at Harry, who took a deep breath and snuggled even deeper under his covers. I rolled out of the bed, opened the door, and found my half-alseep two-year-old standing there with his blanket on his head. "Mom-may, I gotta go pee pee," he bellowed way louder than anyone should at 4 in the morning. I whisked him to the potty and then back into his own bed.

Alarm went off at 5:30-ish. That time was intended for me to make it to the gym on certain days, but not this day-- forgot to switch it to a less heinous time. Annoying. I hit snooze 1.5 times. The first hit was real; I snuck in five minutes worth of intended zzzz's. The second hit only counted for half since at that point I was lying there drowsy yet awake, but too scared to push the "sleep" button. This approach is crappy, because all it leads to is this period of waiting for the alarm to go off again. I dozed off for a second, literally, and was jolted awake by the alarm again. Accidentally hit "sleep" this time which turned off the alarm altogether. Arrrrggghh! Too early to get up, but resetting the alarm for later is too much of a production and the thinking involved would wake me all the way up. Before I could think further, fell back asleep.

7:10 a.m. Eyes flung open, house was eerily quiet. Way too light in the room for it to be the time I was supposed to wake up. Crap! I overslept. Clinic at 8:30 a.m. so barring some miracle, I was officially late at that point. Woke up Harry and, in true Manning splendor, we scrambled all over the house to get ourselves and our little guys ready to go. We also had our usual morning bicker over where backpacks were, is this shirt for Isaiah or Zachary because it's too small/too big, what is that all over Zachary's hands/shirt/pants, and why there is no system for knowing where the socks are. Yet despite this, somehow we made it out the door by a respectable 8:10. In the driveway, I leaned into Harry's driver's side window for a quick kiss, and blew additional ones to the boys who were strapped into their carseats behind him.

Harry: "Love you, babe."
Me: "Love you more."
Isaiah: "Mommy, I love you all the way to Pluto."
Zachary: "I want some soy yogurt."

Jumped into my car, turned on NPR, and was finally on my way to work. Okay, girlfriend. If you hit zero red lights, you are good to go. I hit one red on Ponce de Leon, but the rest of the commute was pretty open. Definitely met qualifications for good traffic light karma. 8:33 a.m. on my dashboard, which is really 8:23 a.m. Wondered for 5 seconds why I bother with the "fast by 10 minutes" clock thing when all along I know the real time. Whatever.

Reached the homestretch--I turned onto Jesse Hill Jr. Drive a.k.a. Grady Street. Woo-hoo! You just might make it, girl! I threw on my blinker and busted a left into the employee parking garage. I already had my badge out and ready--quick "What's up" head nod to the security person, and headed through the access gate. Yes-sirrrr! Manning, you're a punctual rock star!

The NPR guy shakes me into reality with another time stamp.

"This is WABE National Public Radio. Your home for the classics and NPR news. The time is 8:26 a.m."

That's when I saw it. One of those "IN/OUT" spaces was wide open and calling my name. Kimberly! Kimberly! 4 minutes to clinic! I hit the brakes and my blinker. Suddenly, I felt guilty so just sat there for a moment. Thought about Richard-the-security-dude's definition of IN/OUT:

"I guess it's like, 'Oh, let me run in and sign this chart' or 'Whoops, I forgot to get something from my office.'"

Technically, I did have to sign something--the five trillion charts of the five trillion patients I would be seeing with the residents until 5:30 that evening. And hey, I'm sure I could think of something I could use from my office. Then thought about the whole 'honor' business. In a mocking, na-nanny-boo-boo voice I wagged my head and said aloud, "It's on an honor system!"

A horn blew behind me, and nearly gave me a heart attack. When I flung around, this young doctor behind me in a Toyota Prius had his hands up in a "What the hell are you doing" gesture. Pretty sure when I read his lips there was an 'F' bomb in there. Another honk, this one harder. Environmentally clean car, but environmentally foul mouth--go figure. I officially wimped out and drove past the ultra-awesome-but-on-your-honor parking space. In my rearview, I caught a glimpse of Dr. hybrid-car whipping into the spot sans a single stitch of internal conflict. He'd better be running in to sign a chart. Or to get something from an office.

8:40-- scurried into the Green Pod clinic panting after snagging a not-so-great space on the ninth floor--negating all of my traffic light karma, but not my honor.

5:35 p.m.

Running out of the hospital toward the elevator. Now rushing to pick up the kids and wishing I was parked on the ground level. Blue Toyota Prius still "IN" the rockstar parking space, which means the potty-mouthed resident doctor driving it definitely had more than one chart to sign, and more than a forgotten item in his office. IN/OUT my foot. Oh well. He got the space, and saved at least 3.5 minutes on his arrival, BUT you better believe there will be no honor-related honorable mentions for him.
____________________________________________________

9:10 a.m the following day- that Prius was STILL THERE!
(picture me with eyes narrowed, lips curled, hands on hips like "No he di'in't!")

Yes he DID! Dr. Foulmouth had broken every part of the quasi-honor code and had parked his green machine in the IN/OUT spot while on OVERNIGHT CALL. For some reason, I thought anybody who would drive a Prius would automatically be a rule-follower. I have since changed my position. (Yes, I know, I'm being a hater.)

Next time you see Hippocrates, do me a favor and ask him what HE thinks about all of this.

Labels: Hippocratic oath, Life at Grady

Medical myths: Patients must pay if they leave against medical advice

Well, it was close.

I was fortunate to be selected as a finalist in a national essay contest about the frequently-outrageous-and-almost-never-transparent costs of obtaining medical care.

But I didn't win any of the big prizes. Out of eight finalists, I got an honorable mention.

It's not the destination ... it's the journey.

And being selected in the first wave still feels good, like someone out there is listening. You can read a press account about the contest winners here. And if you have a story about the costs of care that you'd like to share, I'd love to hear about it.

I wrote about this issue previously (complete with embedded video!). The scientific paper that discusses the research we did has been accepted for publication and will be out very soon (look for an update on this blog and a tweet or two).

Here, then, is the narrative version of what inspired the work and how we did it. [All names and identifying features of characters in this story have been changed.]

-----

Nora, a third year medical student, came to me in moral distress.

Ms. DiFazio, one of the hospitalized patients on her internal medicine rotation, was frightened to undergo an invasive (and expensive) medical procedure: cardiac catheterization.

The first year doctor ['intern'] with whom Nora was paired, Dr. White, vented to her. "These patients come to us seeking our help and then refuse what we have to offer them," Dr. White steamed.

At the bedside, the intern demanded to know why Ms. DiFazio refused the procedure. When no reason beyond "I don't want to" was offered, Dr. White told Ms. DiFazio that there was no longer cause for her to stay in the hospital.

By declining the procedure, Dr. White informed Ms. DiFazio that she would have to sign out against medical advice (AMA). To signify this she would have to acknowledge that leaving AMA could result in serious harm or death. In addition, Ms. DiFazio would bear responsibility for any and all hospital charges incurred and not reimbursed by her insurance due to such a decision.

"The threat of a huge hospital bill got Ms. DiFazio to stay and take the test," Nora related. "It just seems so wrong to bludgeon a patient this way. Can it possibly be true?"

I'd been out of medical school myself for eight years at that point; until then I'd never heard that patients who sign out against medical advice risk bearing the costs of their hospitalization. What about a patient's freedom of choice, or as we like to call it in medicine, their autonomy?

I told Nora I didn't know, but was determined to find out. Ethically, the notion that patients in the hospital must do our bidding or pay the price seemed dubious. Yet in a world of co-pays, deductibles, and preexisting conditions, a mere grain of plausibility made this idea seem vaguely credible.

I asked around. To my surprise, many fellow attending physicians told me they had been taught the very same thing. My colleagues had trained at teaching institutions around the country, so I began to see this as a pervasive and widely-held belief.

I straw polled some of our residents, and like Dr. White, found that they almost unanimously believed that AMA discharges incurred financial penalties. Where did they learn this?

From their attendings.

From the nurses.

From the AMA form itself, with language stating that the patient, by signing, acknowledges financial risk.

We needed to find the truth.

Colleagues helped us sift through nearly 10 years of AMA discharges from our teaching hospital. And though the results are in press at a medical journal, I can say that out of hundreds of cases of AMA discharges over a decade, in only a handful was the bill was not paid, and that was invariably due to administrative issues, not because of the AMA discharge.

I also thought it important to go to the source: I called the insurance companies themselves. I talked with vice presidents and media relations people from several of the nation's largest private insurance carriers.

Each of them told me that the idea of a patient leaving AMA and having to foot their bill is bunk, nothing more than a medical urban legend.

They were glad to tell me so, as this was a rare occasion of insurance companies looking magnanimous. One director went so far as to poll his company's own medical directors--a half dozen of them--and found that several of them had been taught and believed the canard about AMA discharge and financial responsibility. He was happy to set the record straight.

So patients and doctors beware: The next time you or your loved one has decided that it's time to leave the hospital, don't let us doctors coerce you into staying by threatening you with the bill.

It simply isn't true that leaving against medical advice makes it fall entirely upon your pocketbook.

Future Noras should feel empowered to set the record straight with their interns and residents. Most of all, the Ms. DiFazios of the world won't have to submit to procedures that they don't wish to undergo.

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: Glass Hospital, guest post, John Schumann, patient communication

Satisfied patients use more care, but also have more mortality

Higher patient satisfaction was associated with more use of inpatient care and more health care consumption, but also with significantly greater mortality risk compared with the least satisfied patients.

Is patient satisfaction and marker for better care, or just more of it?

Researchers conducted a prospective cohort study of nearly 52,000 respondents to the national Medical Expenditure Panel Survey from 2000 through 2007. Patient satisfaction was assessed using five items from the Consumer Assessment of Health Plans Survey. They then compared patient satisfaction in one year (year 1) and use in the following year (year 2) for emergency department visits, inpatient admissions, health care spending and prescription drugs, and mortality during a mean follow-up of nearly four years.

Results appeared online Feb. 13 at Archives of Internal Medicine.

More satisfied patients had fewer emergency department visits relative to the least satisfied patients (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.84 to 1.00; P=.06). Relative to the least satisfied patients, the adjusted odds of any inpatient admission during year 2 were higher among the most satisfied patients (aOR, 1.12; 95% CI, 1.02 to 1.23; P=.02).

Patients in the highest year 1 patient satisfaction quartile compared to those in the lowest had adjusted 8.8% (95% CI, 1.6% to 16.6%; P=.02) greater year 2 total health care expenditures and 9.1% (95% CI, 2.3% to 16.4%; P=.01) greater prescription drug expenditures.

During follow-up, nearly 1,400 patients died (3.8%). The most satisfied patients had a 26% greater mortality risk (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.05 to 1.53; P=.02). The association between higher patient satisfaction and mortality remained significant when researchers excluded patients with poor self-rated health and three or more chronic diseases (aHR, 1.44; 95% CI, 1.10 to 1.88; P=.008).

The authors wrote, "Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations. Patient requests have also been shown to have a powerful influence on physician prescribing behavior, and our findings suggest that patient satisfaction may be particularly strongly linked with prescription drug expenditures."

It's up to doctors to manage patient expectations even when they don't fulfill a physician's requests. (Learn more about this from ACP Internist's cover article on the subject.)

An editorialist commented overcoming the "more is always better" attitude remains an enormous challenge because of procedure-based reimbursement, and because of patients' expectations to receive care.

"It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief," the editorialist commented.

Labels: health care cost, patient communication, patient satisfaction

Video offers simple explanation of an accountable care organization

Finally, someone has developed a simple explanation of what an accountable care organization is, and how doctors can explain it to their sometimes frightened patients. The video summarizes how hospitals and primary care physicians will reorganize under these plans, how pay-for-performance works, and how patients will be shuffled in the reorganization of their health care.

Jeff Krasner, a health care communications strategist, created the video, which is hosted by WBUR public radio in Boston. They are also "taking requests for other topics so soporific and esoteric they can only be explained tolerably in a cartoon video."

For a more formal explanation, and more physician-oriented details than an animated cartoon can provide, delve into the resources provided by the American College of Physicians.

Labels: accountable care organization, patient communication, payment reform

Life at Grady: The American Dream

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.

When I walked into the room, I felt it. This palpable heaviness that I couldn't put my finger on. The woman waiting for me in the room was staring straight ahead and didn't even flinch when the door opened.

"Good morning," I spoke quietly.

Her head swung toward my face and she offered a tiny nod. "Good morning," she replied. After that greeting her gaze drifted off to where it had been before I entered the room and her face was an expressionless mask of complex emotion.

For a few moments I simply watched her. Skin of such a strikingly dark hue that it almost appeared black. Dark like night; a shade so uninterrupted and pure that it clearly hadn't originated on this continent. Her delicate hands of that same complexion rested in an idle stack on top of her lap. I nodded back.

"My name is Dr. Manning. I am the senior doctor here today and wanted to come and introduce myself to you. Your doctor told me a lot about you, but I hope you don't mind me speaking with you for a bit."

And to that she nodded again.

This was a straightforward follow-up visit. A quick check to make sure that the issues from her last visit were continuing to move in the right direction. I chatted with her briefly about what had transpired before and since that last visit. Next, I did a focused examination with the intern seeing her that morning. Things were well. She looked good. There wasn't much more to do.

But still, there was that heaviness. Not necessarily heavy all over. More heavy like some kind of lopsided down comforter where all of the feathers have gathered in one area. Not necessarily oppressively heavy, but heavy still.

(Click "more" below to continue reading.)

"What questions do you have for us today?" I finally asked.

"Questions? I have none." Her voice was thick with some kind of accent. Likely peppered by her native African tongue. Each word was careful and formal; almost as if she was consciously translating them word by word from her first language into English. Separated by double-spaces and perfect in their annunciation.

I decided that I, too, should be deliberate about my next words. With her, I also recognized the need to keep things as formal as she which isn't necessarily my style. I followed her lead, but still wanted to know who she was.

"Where did you grow up? Your accent is lovely." I chose that word lovely because it was decidedly formal and also because her accent was just that.

"The Congo." She cleared her throat and sat up in her chair. Then she looked back at me and waited to see what I had next. It felt like an invitation, so I accepted it.

"I've never been to Africa," I gently replied.

"Africa is beautiful," she quickly interjected. "Full of richness, sounds, nature, life. You must go."

You must go.

Beautiful and formal and meaningful. Just like her posture and hands and her gaze. Sorting through my words, I chose these next: "You're right. I must."

She smiled for the first time after I said that. Her strong white teeth were so straight that they almost looked like dentures. And seeing them against the midnight of her skin nearly took the wind from my chest.

"What brought you to Atlanta?" Careful. Deliberate. Quiet. Formal.

"Atlanta is in America. I came to America." That answer was loaded. Her face washed over with some fleeting grief. I knew then that this might be part of that heaviness I was feeling in the room.

"I would guess it's been a big change for you." I waited for a second and sifted through my words again. "Have you . . .Do you like being here?"

Uggh. So much for my careful words. That felt dumb the minute it escaped my lips.

"I came through a lottery system. They enter your name and if you are lucky you get the visa and the green card to come and work in America. Everyone wants to come to America. It is the dream."

Loaded again. My intern sat on the footstool of the examining table and listened. I followed her lead and waited for the patient to continue.

"In my country, I had a good job. I worked for a company. Not manual labor or any such thing. But a good job and I could care for my family. My whole family was there and they were so happy when I won this lottery. I came with my two sons to this country in 2008." She sucked her teeth and looked away. Then staring right back at me she said, "I did not win anything. I lost."

Damn.

I pressed my lips together and looked for the right thing to say. I stopped being careful and decided to just be my normal self. "It wasn't what you imagined?"

"No. Not at all. You come here for this America Dream. The dream that you can be anything and do much more and much better just by coming here. But this America Dream is not what I thought. I know it isn't what anyone in my country thinks."

We sat there riveted, watching her mouth move as her body remained as stiff and formal as before.

"It was better for me at home. Here, I cannot find work. At first, I could. Cleaning jobs, bagging in the Kroger store. But then it got worse. Nothing here for me to do."

"What about your sons? Has it been good for them? Better for them?"

"They were already teenagers. It was hard. They do not look like people here so people were not nice. They came home and said, 'Mam-ee, they treat us like we are aliens from another planet.'" She sucked her teeth hard again and this time rolled her eyes. "And they are smart boys but not A students. So a college scholarship was not there. They are looking for work, too. It is bad. Very bad. And I cannot afford to go back home. No money."

"I'm sorry," I whispered.

"It isn't what they tell you. My country is beautiful. The people work hard and I wish I could go and tell them, 'Appreciate this. Love that this is your homeland and you belong.' That is what I would tell them all."

And so we just sat there in that heavy. Cloaked in the reality of something that I never had to think of. Smothered by those layers of complexity that I initially felt but for which I had now gained insight.

Finally, my intern spoke up. "What will you do?"

And even though that question seemed vague, that patient understood it as the direct question her doctor intended to be. She drew in her chest and straightened her spine once more. And finally with a slow motion blink of her eyes, she paused and then prepared to speak. With that same fiercely searing gaze and her formal staccato English she firmly declared:

"I will survive. It is all I know to do."

And this? This, too, is Grady.

Labels: immigration, Life at Grady

14 quality measures endorsed for palliative, end-of-life care

The National Quality Forum (NQF) Board of Directors has approved for endorsement 14 quality measures on palliative and end-of-life care to address among other topics pain management, psychosocial needs, and care transitions and experiences.

The endorsed quality measures include:
1634: Hospice and Palliative Care- Pain Screening (UNC) (paired with measure 1637)
1637: Hospice and Palliative Care – Pain Assessment (UNC) (paired with measure 1634)
1617: Patients treated with an opioid who are given a bowel regimen (RAND)
1628: Patients with advanced cancer assessed for pain at outpatient visits (RAND)
1638: Hospice and Palliative Care- Dyspnea Treatment (UNC) (paired with measure 1639)
1639: Hospice and Palliative Care – Dyspnea Screening (UNC) (paired with measure 1638)
1626: Patients admitted to the ICU who have care preferences documented (RAND)
1641: Hospice and Palliative Care- Treatment Preferences (UNC)
1647: Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss (Deyta)
0209: Comfortable dying (NHPCO) (maintenance)
1625: Hospitalized patients who die an expected death with an ICD that has been deactivated (RAND)
0208: Family Evaluation of Hospice Care (NHPCO) (maintenance)
1632: CARE--Consumer Assessments and Reports of End of Life (Center for Gerontology and Health Care Research)
1623: Bereaved Family Survey (PROMISE Center)

For this project, NQF sought measures focused on care concerns such as managing pain, weight loss, and depression. It also sought measures that would directly assess and improve the experience of patients undergoing palliative and end-of-life care, as well as the experience of their families, the agency said in a press release. Each measure was evaluated against NQF's endorsement criteria by a panel of providers, measurement experts and consumer representatives.

The endorsed measures include those previously endorsed by NQF and newly submitted measures for initial endorsement. Twelve measures are new. This measure set will help support such efforts, such as enhanced treatment of pain and other symptoms, improved communication between providers and patients, fewer admissions to emergency departments, and increased patient satisfaction, said a spokesperson in a press release.

Labels: end of life, palliative care, quality measures

ACP's Ethics Manual spurs debate about costs of health care

I regard myself as a spirited patient advocate. (What doctor doesn't?) When facing a patient, I try to focus entirely on the patient's interest. My advice is hopefully not tainted by the patient's insurance status or external influences. A patient without medical insurance should receive the same medical advice as a corporate CEO, although the former may reject the medical advice for financial reasons.

As Whistleblower readers know, I am a conservative practitioner of the art and science of gastroenterology. I first developed this medical world view as an intern and resident, and remained a parsimonious practitioner even after completing a gastroenterology fellowship at an institution where patients were routinely subjected to a tsunami of testing.

I don't pull the colonoscopy trigger easily or order many imaging studies. I prefer to prescribe a tincture of time instead of a test. Most patients appreciate this measured approach, although some prefer the tsunami.

I don't practice conservatively because it is cost-effective. I do so because I think it's best for patients. I think it is inarguable that our patients are over-imaged, over-treated and over-tested. I am convinced that there is more than enough wasted money in the health care system to rescue it. Reminiscent of Eisenhower's warning of a military industrial complex, we are now trying to chip away at a medical industrial complex that is an expanding hydra that takes no prisoners.

This is not to suggest that I support Obamacare as a remedy; I don't. For a fuller airing of my Obamacare opposition, I invite you to wander through the Health Care Reform Quality category on this blog. But, our health care system surely needs better health. It has inadequate access for millions of patients, conflicts of interests, misaligned incentives and quality lapses that must be addressed. I think that Obamacare aims to restrain excesses and remedy deficiencies by settling for mediocrity. I'd rather strive for excellence.

Physicians are strongly advised to practice cost-effective medicine, a practice that is often resisted by patients who interpret this as an effort to save money at their expense. Of course, the term cost-effective communicates that the mission is to save dollars and not save lives. Perhaps, the medical linguists who have concocted phrases including pay-for-performance and medical provider and pharmacy benefit manager can create a more appealing label. Here are some suggestions:
--no frills medicine,
--cheapo medicine, or
--medicine on $5 a day.

Seriously, even the hackneyed evidenced-based medicine (EBM) phrase would be a step forward. However, EBM is limited since so many clinical issues that doctors face must be addressed without any available medical evidence to guide us. Perhaps, readers have a suggestion of a better phrase than cost-effective.

Recently, the American College of Physicians issued revised guidelines in its newly published ethics manual that instructs physicians that our responsibility extends beyond the patient before us. Here's an excerpt: "Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly."

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient's interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients.

If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

I think that the merits of cost-effective medicine can be persuasively made to individual patients without having to consider society's needs. Of course, preserving medical resources and health care reform are legitimate issues. But, do they belong in the exam room?

How would patients respond to the following question?

When seeing your doctor in the office, do you expect that he is focused on:
(a) your medical interests exclusively?
(b) your medical interests exclusively on Mondays and Wednesdays?
(c) your medical interests exclusively if you are a concierge medical patient?
(d) your medical interests and society's need to save money?

Physicians are trained advocates. Remind me, who are we advocating for?

As always, your comments are most welcome.

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: ethics, guest post, health care cost, health care reform, MD Whistleblower, Michael Kirsch, professionalism

Young doctors pick up the slack in palliative care

Palliative care is a growing need and a growing career choice for doctors. Professional societies are recommending palliative care at the first diagnosis, and young physicians are flocking toward the field to meet that demand.

American Society of Clinical Oncology issued a provisional clinical opinion that patients with metastatic non-small-cell lung cancer should be offered palliative care and standard oncologic care when they are diagnosed.

The opinion reads, "Although there's no proven survival benefit, substantial evidence demonstrates that palliative care--when combined with standard cancer care or as the main focus of care--leads to improvement in symptoms, quality of life and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care."

The provisional clinical opinion was released in the Journal of Clinical Oncology on Feb. 6.

Currently, palliative care is synonymous with end-of-life care, often within the final month of a patient's life. End-of-life discussions don't take place until then, too. But the provisional clinical opinion comprised seven published randomized controlled trials that showed there have been no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. The panel's expert consensus is that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.

Palliative care physicians have long advocated for earlier integration into health care delivery, citing the advantages. They want to overcome the myth that palliative care equates throwing in the towel.

The Center to Advance Palliative Care reported last year that the number of palliative care teams within hospital settings has increased approximately 138% since the year 2000, from more than 600 then to more than 1,500 today.

Fortunately, there's a growing workforce to potentially match the need. The San Jose (Calif.) Mercury News reports that about 12% of the doctors certified in hospice and palliative care in 2010 are now 36 or younger, citing data from the American Board of Medical Specialties. One factor is that mid-career physicians would have to undergo a one-year fellowship to become certified, which many doctors would find financially prohibitive.

This leaves the younger doctors to pick up the slack.

Labels: cancer, career choices, end of life, medical education, palliative care, residency training, resident

Informatics to see exciting advances in the next few years

These are exciting times for the informatics field, not only from the $29 billion federal investment in the adoption of electronic health records, but also with other developments, such as the new clinical informatics medical subspecialty and the federal investment in clinical and translational research via the Clinical and Translational Science Award (CTSA) program of the National Institutes of Health (NIH). Informatics is an emerging field and profession that is important not only h health care providers but also those who engage in it as practitioners.

Years ago, I used to get asked on a regular basis, What is Medical/Biomedical/Health Informatics? To answer this question, I created a website that attempted to answer it. Later on, I added some voice-over-Powerpoint lectures, which also provided me the opportunity to demonstrate the technologies we use in our distance learning program at Oregon Health & Science University (OHSU).

The site includes my voice-over-Powerpoint lectures, which have now expanded to about 2 hours and 40 minutes, but are still divided into seven segments. On almost every slide, I could go into even more detail. If nothing else, this site will hopefully whet peoples' appetites for the 10x10 ("ten by ten") program, the OHSU biomedical informatics graduate program, and our other programs.

The educational methods I use on this site mirror my on-line teaching, and those readers who are also educators may find them of value as well. I have always found great value in voice-over-Powerpoint lectures, especially using the Articulate tool that provides the slides and sound in Flash format and also allows easy navigation among the slides. I also provide MP3 files of the slide audio (one MP3 per segment) as well as PDF files of the slides themselves (one PDF per segment). In addition, I provide another PDF that has references to all of the papers, reports, books, and other citations in the lecture. The site also contains a list of key textbooks as well as links to some of my papers and to important organizations and other sites for the field.

The materials I post to this blog will be derived from my regular blog entitled, The Informatics Professor. I will select materials of most interest to a general interest audience. I also have a website that describes my work and includes links to many of my published papers.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, is based on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

Labels: Bill Hersh, guest post, informatics, Informatics Professor, technology

Not all doctors fully disclose errors, pharma ties, bad prognoses

One-third of surveyed physicians did not completely agree that they should disclose serious medical errors to patients, two-fifths said they did not completely agree that they should disclose their financial relationships with drug and device companies to patients, and that one-tenth said in the previous year they had told patients something that was not true.

It seems the patient-centered medical home needs a few small repairs.

Researchers surveyed 1,891 physicians from internal medicine, family practice, pediatrics, cardiology, general surgery anesthesiology and psychiatry nationwide in 2009 to find out if they followed the standards on communication laid out by the American Board of Internal Medicine Foundation’s Charter on Medical Professionalism, which was co-authored by the American College of Physicians. The survey excluded osteopaths, residents and those who practiced in federally owned hospitals.

Results are published in the February 2012 issue of Health Affairs.

Nearly 20% of physicians said they had not fully disclosed an error to a patient in the previous year because they feared the admission would trigger a malpractice case, even though some studies show that prompt communication about an error can reduce anger and make patients less likely to sue.

Other important findings from the survey are:
--More than 55% of physicians said they often or sometimes described a patient’s prognosis in a more positive manner than warranted;
--Women and under-represented minority physicians were significantly more likely to follow the Charter’s provisions than their white male counterparts; and
--More than a third of physicians did not completely agree that they should disclose all financial ties with drug and device makers to patients.

Women were more likely to report never lying, fully describing benefits and risks, disclosing financial relationships, and never having told an untruth in the prior year.

Race or ethnicity was significantly associated with never telling a lie and never disclosing confidential information. In both instances, underrepresented minorities were more likely than white or Asian respondents to report attitudes consistent with charter commitments.

International medical graduates were more likely to respond never lying, never disclosing confidential patient information, and never having revealed confidential information.

General surgeons and pediatricians were most likely to completely agree about needing to disclose all serious medical errors to patients, while cardiologists and psychiatrists were least likely (P less than 0.001). Anesthesiologists, general surgeons and pediatricians were most likely to report never having described patients' prognoses in more positive terms than warranted, while internists and psychiatrists were least likely (P less than 0.05). Cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely (P less than 0.001).

Physicians in universities or medical centers were more likely to completely agreed with the need to report all serious medical errors than physicians in solo or two-person practices (78.1% vs. 60.5%; P=0.03). Those practicing in regions with the lowest third of malpractice claim rates were more likely to agree that physicians should fully disclose financial ties to drug and device makers compared with physicians in regions with the highest third of malpractice claims (68.9% vs. 60.9%; P=0.40).

And, even though the survey was anonymous, it's likely to underestimate the rate at which physicians do not comply, the authors wrote. The reasons why are more subtle, however.

"The survey results suggest that many physicians do not completely support the charter requirements related to communication with patients. An alternative interpretation is that treating support for the charter precepts as 'black or white'--physicians either do or do not completely endorse and adhere to these principles--fails to recognize complexities of patient physician communication in everyday practice," the authors wrote.

"Despite the relative clarity and unambiguous language of the charter precepts, many factors can affect how and what physicians communicate to patients," they continued. "Some might argue that knowing when to breach or bend these rules-when individual patients require a different approach constitutes clinical wisdom and true patient-centeredness."

Labels: ethics, malpractice, patient communication, professionalism

End-of-life discussions happen far too late

Most patients with stage IV lung or colorectal cancer discuss end-of-life care planning with physicians before death, but most often, the talks happen much too late.

Many end-of-life discussions occur during acute hospital care, with the median happening a month before death, researchers reported. National guidelines recommend that physicians discuss end-of-life care planning with patients with cancer whose life expectancy is less than one year.

To evaluate the incidence of end-of-life care discussions for 2,155 patients with stage IV lung or colorectal cancer, researchers designed a prospective cohort study of patients from the Cancer Outcomes Research and Surveillance Consortium (CanCORS), a group of patients diagnosed with lung or colorectal cancer from 2003 to 2005 from five large health maintenance organization insurance plans or 15 Veterans Health Administration sites in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama.

Results appeared in the Feb. 7 issue of Annals of Internal Medicine.

In the study, 73% of patients had end-of-life care discussions. Among the 1,470 patients who died during follow-up, 87% had end-of-life care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up.

For the 1,569 patients with end-of-life care discussions, topics included resuscitation (46%) and hospice care (82%). Other topics noted in medical records included palliative care (13%) and venues for dying other than hospice (3%). Of the 1,081 first end-of-life care discussions for which information was available, 55% occurred in the inpatient hospital setting.

Of the 806 first end-of-life care discussions documented in medical records for which provider type was known, participating providers included medical oncologists (49%), general medical physicians (36%), palliative care physicians (6%), other medical specialists (7%), radiation oncologists (4%), surgeons (3%), and other providers (0.5%).

Discussions with oncologists were divided evenly between inpatient and outpatient settings, but discussions with general medical physicians tended to take place in the inpatient setting (73%). Abstracted medical record data were available from visits with medical oncologists for 85% (1,823 of 2,155) of patients, with a median of 6 visits (interquartile range, 2 to 10). However, medical oncologists documented end-of-life care discussions with only 27% of their patients (493 of 1823).

"This finding suggests that acute medical deterioration, and not the diagnosis of incurable cancer, triggers physicians to talk about end-of-life care. The literature has also shown that physicians who have close long-term relationships with patients often wish to avoid end-of-life care discussions," the authors wrote. "Primary care physicians may also have important roles in end-of-life care decision making, but most discussions with general medicine physicians occurred in the inpatient setting, suggesting that these were hospital-based physicians and not those providing longitudinal primary care. Physicians involved in longitudinal care, however, may be best informed about the patient's prognosis and disease trajectory and best equipped to have meaningful discussions about the patient's values and goals."

Labels: cancer, end of life, palliative care, patient communication

Life at Grady: Groundhog Day

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.

It had been a long week on the wards.

One of those weeks where you round and round on the same people over and over and nothing seems to change. Your medications don't seem to be working, your interventions don't seem to be helping, and your consultants don't have much to add. Yeah. One of those weeks.

The kind of week that just might drive a person to drink. That is, if spirits are their thing.

The worst part of that week was that it always seemed to start and end in the same place--the 5B stepdown unit. This floor was dedicated to those patients who were too sick to be on the regular medical floor yet not quite sick enough for the one-to-one nursing required by the intensive care unit. I had two patients on 5B that week and they were both right on the tippy-tip edge of being just sick enough to be in an ICU. But not quite.

This is what made that week suck.

I love the nurses on 5B, so it wasn't them. I even had love for my two patients that were on that floor. But what I didn't love so much was their ruthless medical problems, both of which were alcohol-related.

And these two patients weren't just sick. They were sick-sick. But despite all that, these problems were the kind that, more than anything, were treated with supportive care and watchful waiting. Which after about four days without any improvement whatsoever was getting kind of old.

Oh woe is me, right?

I know. I shouldn't have been complaining about the situation considering I'm the one who signed up to be a Grady doctor, right? But the thing is--the honest to goodness truth--is that this had nothing to do with why they had been hospitalized. No, it wasn't the self-inflicted liquor-thing at all. It's just that. . . .I like seeing people get better. I like seeing them ambulating through the hallways and getting well enough to start complaining about the food. I like when they get to the point of fussing about the poor choices of television channels and leaning over the nurses' station like it's some sort of neighborhood bar.

But these two? They wouldn't budge. No matter what I did.

(Click "more" below to continue reading.)

So every morning, I walked onto the 5B corridor and stopped at Mr. Paxton's room first. He had been admitted for alcoholic hepatitis complicated by alcohol withdrawal. He was mostly somnolent; eyes hidden behind puffy eyelids. In the fleeting moments that his eyes did crack open, the goldenrod hue that had replaced the whites of his eyes revealed the most startling jaundice that I'd ever seen.

Mr. Paxton had decided to stop drinking -- cold turkey. Bad idea considering he'd been drinking for his entire adulthood. Man. That body of his rebelled like nobody's business with seizures, agitation, vomiting and terrifying hallucinations. His blood pressure shot clear up to where they land the Grady helicopters and then his liver went berserk. Totally berserk.

All of this bought him one day in the Grady ICU but once he was stabilized, he came down to 5B . . . and subsequently my team. Great.

His wife looked tired. I remember how thin and haggard she appeared each day at the bedside and almost every time I secretly wondered if she was just worried or if she, too, had a thing for spirits. I never quite teased out which it was.

Anywho. The day Mr. Paxton came to us was punctuated by the arrival of another man who would eventually become his 5B neighbor--Mr. DiMarco. Like Mr. P, Mr. D had a long, strong history of throwing back stiff ones. He also had a doting wife who consistently sat perched by the bed or who could be found quietly ringing her hands in the family waiting area.

Mr. DiMarco was a lot older than Mr. Paxton. He probably had him by a good twenty years or so, and in those years he'd become set in his ways. Despite a weakened heart from alcoholic cardiomyopathy, he was still unapologetic about his daily drinking.

"Old habits die hard," he said to our team the day we'd met him in the Emergency Department. On second thought he sort of puffed those words because he was so short of breath from his decompensated heart failure.

I remember grabbing Mr. D's wrist while we were talking and feeling his speedy pulse. It was going well over 100 and was what most would describe as "irregularly irregular" -- a term reserved for the erratic rate noted in a type of heart dysrhythmia called atrial fibrillation. Though common in several other conditions, both chronic and binge alcohol drinkers tend to be at risk for this. The problem with atrial fibrillation is that the blood begins to sludge inside the ventricles from all that catty-wompus beating--which ultimately puts the person at risk for a stroke.

Mr. DiMarco's love for the spirits hadn't made taking medicines--like the ones designed to control his heart rate or the ones for thinning out his blood to avoid blood-sludge--much of a priority. And so. That galloping heart rate in an already pooped out heart made things worse. So we jumped on him full guns blazing--and seemed to be gaining headway after a few hours. That is until someone called us to ask:

"Was he weak on his left side before?"

Crap.

So yeah. Mr. DiMarco with his weak heart muscle and fast heartbeat now had a stroke to boot. Oh, and did I mention? He was a daily drinker so we could count on his body to start withdrawing just like Mr. Paxton's in five, four, three, two. . . .

*beep, beep, beeeeeeep*

Sigh.

So here is the part where medicine gets real. Extremely real. Where all that novelty starts wearing off and reality starts doing more than just kicking in. It starts kicking your behind.

Oh, and these were just two of the eighteen people we were caring for. Um, yeah.

So every day, I'd come and round in the morning on 5B with my team starting with Mr. Paxton. I'd hear what the intern and resident thought and listen to the update on the labs. Then I'd walk in the room with the team in tow and carefully examine him.

First, I'd say hello. No response. Next, a knuckle in the sternum to see if he'd respond. Nada. Unless you count a flash of fluorescent yellow eye-white as a response.

I'd feel his belly and listen to his heart and look for signs of seizure activity. Nothing.

We'd wrap up the plan and head over to Mr. DiMarco's room two doors down.

*ssshhhh, sssshhhh, sssshhhh, ssssshhhh, sssssshhhhh, ssshhhhh*

The sound of every person pushing their hand under the hand sanitizer dispenser followed by a synchronous sound of hands rubbing together that I can't quite describe. Just like before, the first thing would be a greeting. If his wife was there, it would be to her first. And then to him.

"Hey there, Mr. DiMarco!"

*heavy breathing in response*

With the team forming a semi-circle at the foot of the bed, I'd examine him, too. . .periodically glancing up to ask my resident if the Neurology team had any new recommendations for us beyond their initial interventions.

Nope.

So seriously? That week was starting to feel exactly like that movie Groundhog Day. You know -- the movie where Bill Murray wakes up over and over the same thing keeps happening no matter what. So this was what it was like. No matter what we did each day, nothing changed. At all.

And all because of spirits. Whiskey and bourbon and gin and beer. And sometimes grain.

I would end my day on 5B as well. Hoping that somebody would surprise me by asking me to get them a Co-cola or to even rub some salve on their foot. Something. Anything. But every single day the same thing. Nothing.

On the seventh day, I couldn't take it. The late afternoon sun was beaming through the windows and casting a glare on the electronic medical record. Labs--unchanged. Clinical findings--stagnant. With both patients. After seven days.

Great.

I got up from the nurses' station and slid my coat on. One of my favorite nurses, Ms. J, looked over at me and caught my shoulders curling downward. Next I let out a big, exaggerated sigh and she tenderly said to me, "It's gon' get better, Dr. Manning."

And I looked over at her and then just closed my eyes and sighed again. Because I wasn't sure. Was it going to get better? I mean, yes, technically my week would but would these patients? Would they? The jury was still out on that. On second thought, the jury was about to come to an agreement and I wasn't exactly excited about their decision.

"You know, Ms. Johnson? I don't know what else to do. I'm serious. These two patients just aren't getting any better."

"Well. . .they're not getting worse, Dr. Manning. That's one way to look at it."

"That's not good enough for me. I need them to get better."

Ms. Johnson furrowed her brow and looked over at me as she opened up the tube filled with medications she'd been awaiting from the pharmacy. She shrugged her ample shoulders and raised her eyebrows. "You know what, doc? Sometimes it ain't in your hands."

But this wasn't what I wanted to hear. I wanted my patients to get better. I wanted my hard work and all my fretting and reading and worrying to pay off. So this? This wasn't what I wanted to hear.

"So how do we do this, Ms. J?" I plunked back down on the seat with my coat on and lay my head into the crook of my arm.

"We just think and try and give our best. But at some point you realize it's something bigger involved in all of it, you know?"

I whipped my head up and stared at Ms. Johnson intently. "Well, this might be one of those times because I'm all spent." I gave a sideways smile and released the world's most anemic chuckle. I hate to admit it, but I was spent. I felt worn out and out of gas.

"Maybe, Dr. Manning. Maybe." Ms. Johnson stood still; studying me with her wise eyes framed with graying brows matching the crown of silvery curls on her head.

This was feeling heavy. Heavier than I wanted so I tried to lighten things up. I playfully lifted my hands in the air, "Alright, Jesus! I need a consult! An intervention! A somethin'! Come on and help a sista out!"

And Ms. Johnson and I both laughed out loud which lightened things up indeed.

"You want me to put that in the computer?" Ms. Johnson teased as she headed off to administer her medications. I gave her a playful wink, threw my bag on my shoulder and waved goodbye.

"See you later, Ms. J."

Yeah. See you on Grounhog Day.

The following morning, my resident was in clinic. I'd arrived earlier than normal and decided to sneak by 5B before making work rounds with the interns. The floor was quieter than normal. I attributed this to being the seven o' clock hour unlike our normally later rounding time. I couldn't decide if it was peaceful or eerie. Regardless of which it was, I followed my standard Grounhog Day ritual. First, I stopped at Mr. Paxton's room.

Hmmm.

Bed one had a lady in it that I didn't recognize. I strolled over to bed two -- his bed-- and froze. Empty.

No, no, no! It can't be!

Recognizing that alcohol withdrawal and alcoholic hepatitis can both be life threatening, I had to know that having them both at the same time could not portend the best of prognoses. But damn. I wasn't expecting Mr. Paxton to be gone. I realized how right Ms. Johnson was when she'd tried to encourage me by saying, "At least your patients aren't getting worse."

Well this was about as "worse" as it could get.

I dreaded getting the details. And even more, my heart began to sink as I imagined looking Mrs. Paxton in her tired eyes. I dragged my feet over to the nurses' station and found a clerk sitting behind a computer.

"What happened to Mr. Paxton?"

The clerk seemed to find my anxiety a bit off-putting and didn't hide it one bit. "He's in room 52 now. He got moved," she said nonchalantly. My face washed over with relief and I let out an audible "pheew!"

I turned toward 52 and paused. Well, this was convenient. He was now in the same room as Mr. DiMarco. Mr. Paxton in bed one and Mr. DiMarco in bed two. Imagine that.

I stuck my hand under the foam dispenser and approached Mr. Paxton's bed while rubbing my hands together. My mouth was already fixed and ready to ask my daily rhetorical question and it came out before I could even take in what he looked like.

"How you doing today, Mr. Paxton?"

And do you know Mr. P was leaning over the tray table circling his choices on the food menu? He glanced right up at me with those canary eyes and replied, "I'm good 'cept for y'all ain't got nothin' for me to eat. What's the RE-NAL DIET? I don't wont this. Or the no salt."

Seriously? I almost leaped on that bed and patted his face. I wanted to squeal with delight but instead kept it cool. "Mr. Paxton, you're talking! I'm so happy to hear you talking!"

And the whole time I examined him, he bitched about that diet and I swear it was music to my ears.

"I'm 'on have my wife brang me some real food up here today. She on her way."

"She is? That's great!"

Mr. P acted like he hadn't been knocked out for seven days and looked at me like I was crazy. "Seem like every channel y'all got is Jerry Spranger or a damn judge show!" he went on.

And that? That really made me want to waltz around his room with him.

Finally, I stepped out of the room to reapply the hand sanitizer before going to Mr. DiMarco's bed. "Well at least somebody has turned a corner," I mumbled to myself while extending my arm. Just as my hand went below the dispenser, I froze in my tracks. . . .recalling the last few words exchanged between Ms. Johnson and me the night before. I could hear her voice like she was right there:

"We just think and try and give our best. But at some point you realize it's something bigger involved in all of it, you know?"

I nervously pushed the dispenser over and over allowing way to much foam to go into my hand. For some reason, my pulse was quickening and I didn't know why.

What if. . . .? No.

When I stepped around the curtain, the first person I saw was Mrs. DiMarco. Her hand was wobbling and she was carefully scooting a cup of water with a straw in it up to husband's lips. The hairs on my neck began to stand at ninety degrees.

"Good morning, Mr. and Mrs. DiMarco," I spoke quietly.

Mrs. DiMarco looked over at me and smiled sweetly. "Oh hello, doctor," she said with a Kathyrn Hepburn-esque tremor in her voice. Her lips quivered gently as she shifted that smile back to Mr. DiMarco. From the corner of my eye I saw his left hand and arm moving toward the cup.

No. Way.

"He's moving the left side now?" I asked incredulously.

"Yes. It started late last night," Mrs. D responded while still focused on her husband.

"Wow." I couldn't hide my amazement at his improvement.

"Well," she spoke in her bumpy voice, "the Neu-rologists did say that we could start seeing some improvement and that it was just hard to say with all the rum fits and all."

The spirits. That's right.

By my second visit to 5B late that afternoon, those two guys were in there talking crap about the food and the television together. It was unbelievable.

Why they were put in the same room, I have yet to find a solid explanation for it. At least, not one that makes clinical sense. And I promise you--as sure as my name is Kimberly Manning -- this series of events is a true story. Hand over heart.

Okay, honestly? Y'all know I'm a person of faith. I've always been transparent about that among other things when writing here. But this? This shook me to my core. It really did.

"We just think and try and give our best. But at some point you realize it's something bigger involved in all of it, you know?"

You know? I think Ms. Johnson was right. There has to be something bigger involved in all of it. The human body and healing it is way too complex for it to be just explained by what's in our books. Regardless of what you believe or don't believe or are undecided about how you feel on what that "something bigger" just might be. . . . there are just some things that do not make clinical sense. Changes in patient outcomes that seem to happen almost independently of the things we are doing. Sometimes for the worse. And other times for the miraculous better.

No. I'm not saying that what we do medically isn't extremely important. But I am saying that I recognize that I am just a piece in a puzzle. A puzzle that is far more complex than even I understand. And that? That week on 5B? That was about more than just me, man.

At least that's what I believe.

Labels: Groundhog day, Life at Grady

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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, February 29, 2012

Life at Grady: Yes, we can

Tuesday, February 28, 2012

The new subspecialty of clinical informatics: Some (but not all) questions answered

Monday, February 27, 2012

Mindfulness in palliative care

Friday, February 24, 2012

Our broken system example #2: Fat cats

How medical students should spend their final free summer

Meaningful use adoption sparse as CMS previews stage 2

Thursday, February 23, 2012

Hospital staff worried about culture of reporting mistakes

Wednesday, February 22, 2012

Life at Grady: What would Hippocrates say?

Monday, February 20, 2012

Medical myths: Patients must pay if they leave against medical advice

Satisfied patients use more care, but also have more mortality

Thursday, February 16, 2012

Video offers simple explanation of an accountable care organization

Wednesday, February 15, 2012

Life at Grady: The American Dream

14 quality measures endorsed for palliative, end-of-life care

Tuesday, February 14, 2012

ACP's Ethics Manual spurs debate about costs of health care

Monday, February 13, 2012

Young doctors pick up the slack in palliative care

Friday, February 10, 2012

Informatics to see exciting advances in the next few years

Thursday, February 9, 2012

Not all doctors fully disclose errors, pharma ties, bad prognoses

Wednesday, February 8, 2012

End-of-life discussions happen far too late

Life at Grady: Groundhog Day

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