American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, February 26, 2013

Hospitals are still awful: movement toward patient centered care and Eric Topol's idea

First a disclaimer: People often receive compassionate, considerate and effective care at hospitals. They have countless interactions which impart the miracle of human caring and enrich their lives. It is also institutionally prevalent to have haphazard care with poor communication, near misses and avoidable misery.

I have been working at a university hospital emergency room as part of a mini-fellowship in bedside ultrasound. It is the first time I have spent significant time entirely dedicated to an emergency room since I was a medical resident about a quarter of a century ago. As an internal medicine physician who works in hospitals, I have spent one or two hours at a time relatively often in emergency rooms taking care of patients who were admitted to me on their way to the medical floor, but that is not the same as staying there, seeing the more and the less ill, the folks who may go home and may get admitted, watching the rhythm of the department over time.

People come to emergency rooms for many reasons. Often they come because they need to see a doctor, but can't get in to one in an office because the doctor is busy or doesn't accept their insurance, or they don't have any way to pay, no money and no insurance. They come in because there is something wrong that they have decided needs to be dealt with now. The problem may be a true emergency, something that if left another day will lead to death or disability, or just something that has become intolerable and appears, from the patient's view, to have reached a level where any delay in treatment is unthinkable.

They also come in, brought by ambulances or police or concerned family or friends, for drug overdoses, stab wounds, car and motorcycle accidents, assaults. They come in with no regard to whether the doctors in the emergency room are already busy, and they do not pace themselves. Three patients with stab wounds may arrive in 15 minutes, topped by a cardiac arrest. Usually the universe doesn't do this to us, but milder versions happen all the time. The acute treatment of the critically ill patient is often beautifully choreographed, efficient and successful. Treatment of the less critical patient, not so much.

Patients are brought back to the actual department where, in this ER, they are evaluated in curtained bays, with privacy of their stories ensured only by the ambient noises of crashing and yelling and beeping. Some newer emergency departments actually have rooms with doors, but not the one I'm hanging out in now.

They are evaluated by resident physicians, attending emergency room doctors and sometimes students. They are cared for by nurses whose attention is constantly pulled in many directions by a constant flow of patients with varying urgency of need. After a patient is evaluated and an initial treatment plan is developed, they get IVs, usually, medications, sometimes, lab tests usually, radiological procedures frequently, and often a bedside ultrasound by someone like me, in training. Then they wait. And wait. And their relatives, who have to go to work in the morning, which is now only a few hours away, sit and wait. Occasionally someone comes by to tell them what they are waiting for, but not very often.

Their labs are completed, and if there is nobody else more critically ill, some doctor in the team checks them and thinks again about what should be their ultimate outcome. And they wait, not knowing what is happening. They wait, lying on plastic covered gurneys which are covered with sheets that slide down and bunch up underneath them. Sometimes, but not often, primary doctors or consultants who are familiar with them are contacted. If they are admitted to the hospital they are moved to a more comfortable room in a new building (which must seem like heaven in contrast with the ER) but they have to wait hours to be seen by the admitting physician and moved to said room.

After 25 years in internal medicine practice, I am much more familiar with what happens to patients when they do reach the hospital wards. They tell their story, which they have told at least five times already, with multiple interruptions, to a new crew of people, nurses, specialists, new doctors from a different shift. They worry that the whole story that they told before has not been communicated and that what is being done to them may be wrong or unnecessary because of miscommunication. They hear about planned tests, have tests, wait for hours for results, or days, or never hear the results at all. They get treatments delivered by nurses along with explanations given by the nurses, which only occasionally bear any resemblance to what they doctor was thinking when the treatment was ordered. (This is not the fault of the nurse, but due to the system in which nurses and doctors rarely discuss treatment plans in any meaningful way.) They also get explanations from specialists which differ from those given by hospitalists, and maybe get to spend a little more time talking to social workers or discharge planners who sometimes have a better idea of the big picture than anyone else on the team.

The inevitable result of all of this is that patients, except those who are unusually generous of spirit, are frustrated and often grouchy, occasionally spitting mad. They are also not made well in the most expedient of manners, and often are made sick on the way to being made well, or instead of being made well.

Eric Topol, MD, a renowned cardiologist and inventor of novel medications, and more recently a questioner of tradition, employed by the Scripps Research Institute studying innovative medicine, has given a brief video talk about ways in which hospital stays and doctor visits might be replaced by video chats and remote transmission of physiological data. I think that he is being short sighted and has forgotten that many people who end up in hospitals do so because there is no unpaid human who will or can care for them outside of a hospital, either because they have become so darn sick they can't even make it to the bathroom, or because they are homeless or marginally housed, and that three-dimensional health care is fundamentally what humans do for each other. Still, I love the fact that he is talking about ways to radically change medicine.

Many organizations are developing systems to make medical care more "patient centered." This term was initially coined in the 1960s and was defined as systems that "take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness."

We physicians sometimes think of this kind of thing as fluff, and unworthy of our skills in fighting off death and disease in their myriad forms. Movement in the direction of patient centeredness, with attention to the systems which make medical care unkind, is vitally important, and should legitimately absorb a significant portion of physicians' considerable problem solving skills.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand 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.

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
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 Infection Prevention
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 Iowa City, IA, 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.

Everything Health
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.

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
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.

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.

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.

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.

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, 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.

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).

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.

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) 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.

Peter A. Lipson, MD
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 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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