Friday, December 19, 2014
Do hospitalists miss opportunities to talk about healthy habits and preventive medicine?
As hospital doctors, we are extremely busy people. Our days whiz by, often without a moment to rest or take a deep breath. We are in “the zone” and rightly completely focused on getting our patients better and in a position when they can hopefully leave the hospital. We have chosen a specialty which is all about secondary level care, one where we know that we are not going to be seeing our patients in the office afterwards. Our encounters and relationships with them may thus seem very brief and to the point. Most of us probably believe in primary prevention too, but feel that it is outside the scope of hospital medicine.
For example, apart from the brief spiel our diabetic and heart failure patients may get about the importance of dietary compliance, how much time do we really spend talking about wellness and preventive medicine with our patients? As a physician with an interest in this area, here I believe is a massive missed opportunity. As you form close relationships with patients and their families over their several day stay, don't underestimate your power as the attending physician to exert influence over what they do when they leave the hospital. Even a passing question such as “Do you eat a lot of vegetables?” Or “Ever thought about getting more exercise?” can really register with a lot of patients, and could help bring about positive changes in their lifestyle habits after you see them. Many patients and families can really open up to you when you bring this up.
Simply thinking that we can “leave it to the primary care physician” to address, is not the right way. With the epidemic of lifestyle related conditions in society, it is the least we can do as doctors. I'm not talking about spending excessive amounts of time emphasizing wellness and preventive medicine during your hectic day, but just give it a bit of thought next time you're seeing patients. I've often been pleasantly surprised by people that I bump into again after their hospital stay who tell me with smiles on their faces that they are eating more fruits or taking longer walks after I suggested it to them (lifestyle changes that, I may add, will probably have higher morbidity percentage benefits than many medications I may have prescribed them). You may be surprised too with where your good common sense doctor advice may lead for your patients.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Thursday, December 18, 2014
Conflict of interest and managing scandal
I have had the privilege of chairing the Industry Relations Conflict of Interest Committee at the Indiana University School of Medicine, the medical school where I work, over the past year. I have learned a lot about interactions of academic physicians with industry, and have certainly heard differing opinions on the topic. Our policies were recently approved (unanimously, I might add!) by all of the pertinent committees, and already, many faculty have had comments and questions about specifics of the policy.
One common theme that we have also heard is that "regulatory agencies and administrative bodies" have hurt the field of medicine. I certainly understand the additional burdens of what it takes to practice medicine, and how those burdens can actually damage the patient-physician relationship. However, when one looks at why conflict of interest policies are put in place, one needn't look very far to see why it is necessary.
Here is a prime example. The Journal of Patient Safety had to deal with this recent example with its own editor. Dr. Charles Denham, the [now] former editor of the journal, failed to disclose his own financial conflicts of interest with organizations which paid him. This impacted recommendations he made with respect to clinical guidelines that center around optimizing patient safety.
What is interesting to me is that sometimes, how one handles a scandal can be as important as the scandal itself. Covering it up, hiding it, or trying to sweep it under the rug are all examples of ways that don't work. It is amazing that it is this same sense of "doing the right thing" that parents try to teach their children. What impressed me in this example is how the journal chose to address this. The journal has opted to tighten its own policies and processes around conflict of interest, for authors, editors and others who make decisions about articles within the journal. They even published an article describing what they plan to do.
For anyone wondering how to handle a scandal, THIS is how to handle a scandal. Admit the wrongdoing, describe what steps need to be taken for the better, and, simply, apologize. As written in this NPR piece, "airing the dirty laundry," while painful, is a necessary step.
I applaud Dr. Albert Wu, Dr. David Bates and the journal editors for demonstrating the right way to manage this situation. I think this is a great learning experience for the patient safety movement, for editors, and for all physicians who interact with industry. Conflicts of interest are complex, but it all comes back to the fact that there is a public trust that must be put front and center. If we violate that trust, then we have done a disservice to the profession, to ourselves, and, most importantly, to our patients.
Alexander M. Djuricich, MD, FACP, is Associate Dean for Continuing Medical Education and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. This post originally appeared at Mired in MedEd, where he blogs about medical education.
Help me understand how you react to uncertainty
Uncertainty is a common experience in health care. For an upcoming book and ongoing research project, I want to be in contact with patients, families, and caregivers to learn their strategies for approaching, dealing with, and understanding such uncertainty.
For example, Ms. A. has back pain unaccompanied by underlying serious disease. She has no way of knowing whether it will go away in weeks, months, or not at all. She wants an MRI, which accepted evidence indicates will neither aid in treating her pain nor reassure her.
On the one hand, both she and the health care provider would like to do “something” as a sign of care; on the other hand, we want to harm neither Ms. A (with tests/procedures that won't work), nor society (afflicted by a health care system which costs too much, delivers poor care in comparison to other systems, and treats people unequally).
There are many scenarios in which treatment is pursued despite evidence showing it does not work more than placebo. For example, hormone treatment in the patient with local (not metastatic) prostate cancer; repeated CT scans for thyroid nodules without symptoms; treatment of ductal carcinoma in situ (DCIS), mammograms in a patient without significant family history more often than every 2 years.
How do you as a patient, family member, or caregiver seek the best care in such a situation, where things are uncertain and more tests/procedures might not work? What strategies do you use? What should health care providers do? Please be in touch with me to help guide this work. zberger1 at jhmi dot edu
See the presentation below for another depiction of the problem.
How Do You Deal With Uncertainty In Healthcare? from 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. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
Wednesday, December 17, 2014
Patient safety, Swiss cheese and the Secret Service
I was listening to the news on my way to work last week, and heard a story about the review conducted after the well-publicized security breach at the White House. Like many people, I was shocked when the story of the fence-jumper first broke. How was it possible that some guy with a knife managed to get over the fence, cross the lawn, enter the White House and get deep into the building before he was stopped? The answer, according to NPR's reporting of the Department of Homeland Security investigation is that a whole sequence of events made it possible:
It turns out that the top part of the fence that he climbed over was broken, and it didn't have that kind of ornamental spike that might have slowed him down. Gonzalez then set off alarms when he got over the fence, and an officer assigned to the alarm board announced over the Secret Service radio there was a jumper. But they didn't know the radio couldn't override other normal radio traffic. Other officers said they didn't see Gonzalez because of a construction project along the fence line itself. And in one of the most perhaps striking breaches, a K-9 officer was in his Secret Service van on the White House driveway. But he was talking on his personal cell phone when this happened. He didn't have his radio earpiece in his ear. His backup radio was in his locker. Officers did pursue Gonzalez, but they didn't fire because they didn't think he was armed. He did have a knife. He went through some bushes that officers thought were impenetrable, but he was able to get through them and to the front door. And then an alarm that would've alerted an officer inside the front door was muted, and she was overpowered by Gonzales when he burst through the door. So just a string of miscues.
The explanation rang true. Of course it was no “1 thing” that went wrong; it was a series of events, no 1 of which in isolation was sufficient to cause a problem but, when strung together, led to a catastrophic system failure. The explanation also sounded familiar. It is a perfect example of the “Swiss cheese” conceptual model of patient safety.
First articulated by Jim Reason, the Swiss cheese model holds that serious adverse events that occur in the context of complex systems are generally the consequence of multiple failures, not the fault of a single individual. In the case of a serious patient harm event (e.g., operating on the wrong body part), thoughtful analysis inevitably finds that many things have to go wrong for the surgery to occur. Indeed, just as the Secret Service has multiple layers of barriers around the White House to prevent an intruder from reaching the President, patient safety experts speak of “layers of defense” within medical systems that are designed to assure that small errors caused by human frailty don't allow harm to “reach” the patient.
The “Swiss cheese” description derives from the visual shorthand of imaging a series of slices of Swiss cheese, each of which represents a system defense. In the case of the White House, the perimeter fence, the guard dog and the building alarm are each like separate pieces of cheese. The holes represent imperfections or failures of each slice. For the intruder to get through them all, the holes in the cheese have to line up in a particular way. If the holes don't line up, the fence fails, but the dogs respond, then the system works.
For a wrong side surgery to occur, it may take a similar string of failures: maybe the surgical drape covered the surgeon's pre-op marking and the patient had bilateral disease, and the surgeon working in an unfamiliar OR, and so on.
Addressing patient (and Presidential) safety is almost never about finding the single person who failed at his or her task, or about an easy fix. It is about understanding how complex systems work and creating a culture of safety to continuously improve them. I hope the Secret Service takes that approach, instead of just fixing the fence and firing the guy who was on his cell phone.
What do you think?
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
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- Do hospitalists miss opportunities to talk about h...
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
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.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
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.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
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.
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.
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.
Mike Aref, MD, PhD, FACP, 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.
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.
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.
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.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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.
Elaine Schattner, MD, FACP, 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.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
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).
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
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
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.
Peter A. Lipson,
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.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
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.
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.
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.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.