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Archive for December, 2008

Friday, December 26th 2008

The Time Has Long Come

I’m in my fourth year of medical school. In a matter of months I’m going to be a physician. Until October of 2008, thirty-seven months into my education as a medical student, I had never even seen a paper medical chart. My only rotations were at a county hospital with a strong commitment to EMR and at government sites. I rotated at both VA and DoD hospitals both with strong nationally connected electronic medical record systems. I had also never seen any numbers on the prevalence of electronic medical records and so I assumed that most major hospital systems, at the least ones with integrated physician practices such as in much of academia, must also have full fledged EMR systems.

But over two months, doing away rotations, I learned hard and fast the reality. I rotated at institutions which, like most of the country, still rely on paper charts for the majority of the patient’s record. Sure they often times have lab data on the computers and certainly, nowadays everyone has a PACS. But they’re missing out on so much more.

Over those two months I had to teach myself certain skills which really should no longer be a part of the delivery of health care in this country. I taught myself how to write quick, illegible and uninformative notes by hand. I taught myself how to fight off nurses and social workers for patient’s charts and then hoard them. I taught myself to just give up hope of trying to decipher the handwriting on a consult note and just page the service to hear their recommendations over the phone. I taught myself to memorize my resident’s provider numbers because I knew the nurses were going to be paging to confirm orders which they couldn’t read. I taught myself the most likely places for “missing” charts to be. I taught myself the most likely places for various documents to be filed in the chart.

Nowadays I’m on the interview trail. It is the long and arduous journey to find out where I’ll do residency. And I laugh a little bit inside when residents try to convince the interviewees that it is a good thing their primary teaching sites still use paper charts because it’s “faster and easier” to write notes by hand. That’s novice talk.


The Myth Physician Handwriting Is Worse Than The General Public’s Persists…

Virtually all computerized note writing systems allow templates or, at the least, click at you go note building forms. With three key strokes a resident in my home neurosurgery department can bring up a virtually completed consult note on a patient with any major, common neurosurgical issue. A few buttons on the keyboard to personalize the note for that specific patient and the note is done at least as quickly as if they had scribbled it on a piece of paper down in the emergency room. There is a learning curve and it represents one of the largest non-financial obstacles to the implementation of EMR systems. But I simply refuse to believe, that once the system is known to all and full implemented, that a electronic medical records system does not improve the efficiency of just about any practice environment. From the huge general hospital to the small rural primary care practice.

Beyond efficiency EMRs offer significant patient safety benefits. Poor handwriting or misinterpretation of orders are certainly a source of medical errors. No, electronic order systems, don’t eliminate these in full but they do reduce the risk. Handwriting becomes a non factor. Most major EMRs offer physicians advice on drug-drug interactions, limit physicians’ ability to order too much of a medication and/or check orders against a patients list of diagnoses and try to make sure the physician is ordering what he or she really wants to. Linked dispensary systems, like Pyxis, can limit the risk of nurses or others giving patients the wrong medication. And electronic patient identification (such as barcodes on patient arm bands) can significantly limit the delivery of medication or therapy to the wrong patient.

Obviously there are some major hurdles to the widespread implementation of electronic medical records. Included amongst these are technical issues and of course, in large part, the initial expense of implementation.

But these expenses are far offset by the benefits and most providers who are calculating it otherwise are fudging the benefits.

For hospitals the investment in well designed and implemented electronic medical records pays for itself in pretty fashionable time as some experiences have demonstrated. For private practices the initial overhead can be more daunting, admittedly. But private practitioners shouldn’t delude themselves that the benefits aren’t there. Yes, the patient safety issues for a largely ambulatory practice are less pressing than in the inpatient setting, if still present, but other benefits abound. Consider a new Annals of Internal Medicine study which may demonstrate that physicians who use EMRs may be less likely to pay malpractice claims.

I am a strong proponent of electronic medical records. However my point, in conclusion, is a nuanced one. For major medical centers, especially academic ones with integrated physician practices, to not have full fledged electronic medical records at the present time is inexcusable. For private practitioners, we should be working to bring electronic medical records as a reality. The lifting of Stark law restrictions was a good start, if the current economic conditions mean health systems are currently not as inclined to invest in EMR systems for their physicians as would be ideal. Hopefully federal subsidization will help the spread of electronic medical records into the private sector at an increased pace. Indeed P4P efforts should include the implementation of EMRs for increased reimbursement. Of course we all know how CMS’ P4P plans are doing. Still, I can dream

I’m serious about this issue. Ever residency interview I’m at I ask about the hospitals’ computer interface and what the physicians can and cannot do from the computers. A more substantial roll out of electronic medical records is long overdue.

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Thursday, December 25th 2008

Secretary Blago


Crazy Ass Press Conference Might Not Begin To Describe It

Remember when Blagojevich was a rising star in the Democratic party? Me neither since he’s been at least a peripheral target in corruption investigations for at least the last five years. But whatever glimmer of future stardom he had left is dead.

The Illinois Governor has had some serious accusations levied against him by U.S. Attorney Patrick Fitzgerald. Basically, the most serious charge is that he was trying to peddle an appointment to the Senate seat vacated by Barack Obama for either some petty cash with which to buy Christmas presents for his kids or personal favors.

[T]he most stunning charge is that Mr Blagojevich, who can appoint a nominee to hold Mr Obama

Thursday, December 25th 2008

A Holiday Edition of Grand Rounds

Grand Rounds is at Highlight HEALTH. Walter Jessen has put together a little present for all the medical blog carnival readers. You should go open it.

Thursday, December 25th 2008

Right of Conscience

President Bush’s second term has been rife with discussion over the rights of health care providers to refuse care if such challenges their religious and moral beliefs. Such debate often centers around abortions and contraception. Last year the Bush Administration “reenforced” the right to refuse to provide contraception.

Now, in a rule sure to be killed within Obama’s first 100 days in office, the Bush Administration has provided a further expansive definition of health care worker’s right of conscience.

[Secretary Mike] Leavitt initially said the regulation was intended primarily to protect workers who object to abortion. The final rule, however, affects a far broader array of services, protecting workers who do not wish to dispense birth control pills, Plan B emergency contraceptives and other forms of contraception they consider equivalent to abortion, or to inform patients where they might obtain such care. The rule could also protect workers who object to certain types of end-of-life care or to withdrawing care, or even perhaps providing care to unmarried people or gay men and lesbians.

While primarily aimed at doctors and nurses, it offers protection to anyone with a “reasonable” connection to objectionable care — including ultrasound technicians, nurses aides, secretaries and even janitors who might have to clean equipment used in procedures they deem objectionable.

The order denies federal funding to any health care delivery entity who either doesn’t document their steps to protect provider’s right of conscience or who violates such a right. The right of conscience is far from a new idea but these new broad federal rules bring the ethical debate back into the forefront. After the Roe v. Wade decision many states jumped to conscience laws. Indeed, the vast majority of states now protect some form of right of objection to care based on a provider’s beliefs. But the new federal rule seems exceptionally broad.

I admit that I support the move. Opponents of the move see health care as a political right; something that providers are obligated to provide. I’ve obviously never been a fan of positive rights. I’ve obviously never been a fan of a right to health care. But I’ve devoted thousands of words to that point of view through this blog.

What I really want to discuss here is the simplistic place public discourse over this issue is taking place at. The framework proper framework for a debate is over the weight of a right of conscience versus a right to health care. Take some of the ideas from a discussion the Washington Post hosted with readers,

Thanks for these eye-opening articles. This is scary stuff. We rightly expect “professionals” in whatever field to perform their duties in a “professional” manner, perhaps more so when they are licensed by the government. If there are duties that conflict with your religious beliefs, DON’T go into that field.

[...]

Our right to religious freedom is absolute. What is not absolute, however, is any “right” to be a physician or a pharmacist or to engage in any licensed profession when one’s religious beliefs interfere with his or her ability to practice that profession. My question is, what under our laws, constitution, or traditions permits a licensed professional to retain his or her license to practice in the face of any inability to discharge the duties of that profession faithfully, whether the impediment is religious, physical, or some other factor?

[...]

When did a professional’s religious beliefs become more important than a state’s licensing board? All of the professionals described in the article are governed by state regulations (and were trained/educated to meet standards); how can they ‘cry’ discrimination on the basis of religion if they knew beforehand what the position entailed?

These opinions are scary because they assume much and take the debate away from more fundamental points. The social construct of a profession is so far from inherent. We have a very simplistic view of the situation from most health care consumers. They place obligations on providers and are really unable to defend them; they simply know they exist because physicians or pharmacists or nurses chose to go into that profession and because of that patients are owed something. Weird, non sequitur causality.


I’m Proud of the Social Status of American Medicine

I’m proud of medicine’s status as a profession. I’m proud of the respect it is granted in society. I’m proud of the self governance it is left to. But the idea the being a member of such a profession places an obligation to provide whatever the patient or family wants, which is what the expectation has arisen to, is ludicrous. Now medicine isn’t, at all times, completely about merely healing the body. I admit. But, one key, pragmatic point I would like to make is that the issues at hand here often do not involve curing a pathology. The major ethical issues this rule tries to protect health care providers from having to participate in are things like: contraception, abortions, sterilizations, withdrawal of care, etc.

I suppose we shouldn’t worry too much. We’ll see how long these expansive rules survive once the new administration come into the Oval Office.

Monday, December 22nd 2008

Copper Versus Superbugs

A small study in the United Kingdom found that replacing door handles, faucet fixtures and toilet seats with copper replacements could work as an infection control method.

During the ten-week trial on a medical ward, a set of taps, a lavatory seat and a push plate on an entrance door were replaced with copper versions. They were swabbed twice a day for bugs and the results compared with a traditional tap, lavatory seat and push plate elsewhere in the ward.

The copper items had up to 95 per cent fewer bugs on their surface whenever they were tested, a U.S. conference on antibiotics heard yesterday.

You of course want to see an actual effect on nosocomial infection rates, but this is still interesting. And this is always good,

Lab tests show that the metal kills off the deadly MRSA and C difficile superbugs.

Monday, December 22nd 2008

A Mature Tumor

While I was away on the interview trail a very interesting story hit the media wires. In Colorado a pediatric neurosurgeon went in to sample/remove a tumor from a young child’s brain. What he found was that the tumor contained fully formed anatomical parts. Included was a fully formed foot.

“It looked like the breech delivery of a baby, coming out of the brain,” Grabb said. “To find a perfectly formed structure (like this) is extremely unique, unusual, borderline unheard of.”

[...]

Sam’s parents, Tiffnie and Manuel Esquibel, said their son is at home now but faces monthly blood tests to check for signs of cancer or regrowth, along with physical therapy to improve the use of his neck. But they say he has mostly recovered from the Oct. 3 surgery.

“You’d never know if he didn’t have a scar there,” Tiffnie Esquibel said.

The question is how did this happen.


The Foot In Surgery

Teratomas are a type of germ cell tumor which can occur in the brain. They develop from embryological cell lines and often develop characteristic mature tissue including skin, hair, teeth. Cases have certainly been reported of even more complex structures appearing in teratomas, including eyes. Approximately one hundred cases of a situation called fetus in fetu have been reported. In such cases a born child ends up having parts of his assumed twin growing somewhere inside of him. Fetus in fetu often have even more complex structures, including what often appear as fully formed limbs and organ systems. As in this case.

I’m not sure if a case of fetus in fetu has ever been reported inside the cranium. Still, teratomas often occur there and in some people’s opinion fetus in fetu should be considered a highly rare form of teratoma. In anycase, this is an incredibly rare and interesting discovery. My thoughts are with the family but if the AP report is to be believed the kid is doing well.

Tuesday, December 16th 2008

The Best of 2008 At Grand Rounds

Laurie at A Chronic Dose has Grand Rounds up this week. For this edition she asked bloggers to go back the full year and select their best posts since January.

Go check it out.

Thursday, December 11th 2008

Grand Rounds At Sharp Brains

Grand Rounds has been up since Tuesday at Sharp Brains. The blog of the ‘cognitive fitness’ consulting firm usually puts up interesting posts on brain training and neuroscience. This week they’ve posted the best of the medical blogosphere.

The Pre-Rounds column profiling Shapr Brains and their co-founder, Alvaro Fernandez, can be found on Medscape.

Wednesday, December 3rd 2008

Protecting Patients From The Ivory Tower

When a medical student graduates as a physician they go on to residency. Such a time in a physicians life has been glorified by shows like Scrubs and Grey’s Anatomy.


My Goal Is To Be Like J.D. During Residency

Residency is a grueling apprenticeship. In the American and Canadian model it probably represents one of the most time consuming apprenticeships on earth. Residents play a huge role in patient care and several years ago the question over resident errors when they were tired led to rules which restricted how much residents could work. Technically residents are not supposed to work more than 80 (or in some cases 88) hours a week; averaged over four weeks.

Questions of compliance, especially in the surgical specialties, remain.

Nevermind, because now a panel from the Institute of Medicine have recommended further restrictions on how much residents can work.

While the new recommendations do not reduce overall working hours for residents, the report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.

The committee also called for better supervision of the doctors-in-training; prohibitions against moonlighting, or working extra jobs; mandatory days off each month; and assigning chores like drawing blood to other hospital workers so residents have more time for patient care.

Okay, to be fair, it is a better report than some of the working drafts that were leaked. Initially it looked like the panel was going to propose that the 80 work week be reduced to a 56 hour work week. That would’ve truly been insane.

Yet still, the Institute of Medicine panel has very poor perspective on what they’re delving into.

There is a very sound argument that surgical residencies are the most time consuming and that neurosurgical residencies are the most grueling of the grueling. I want to be a neurosurgeon. I’m not going to get pumped up and claim that I’m hyped about the long work hours. But they’re necessary.

The prospect of mandating restrictions on resident work hours in a neurosurgery residency is dangerous. I actively oppose both the current work hour restrictions and the new proposal from the IOM.

As I said, the IOM panel has a very poor perspective. It is difficult to degrade the efforts of a panel composed of such esteemed individuals but consider the following: nearly half of the panel is non-physicians and the panel included just one surgeon (an otolaryngologist).

A panel in which eight of seventeen members are not physicians and in which only one of the members is also a member of a surgical specialty; the specialties to be most effected by the recommendations (if implemented). I cannot believe, even with all the credentials of the panel members and the ‘exhaustive’ input the panel solicited, that anyone is taking this study seriously. It is laughable for a group to be making such recommendations without the first hand experience to bolster their voices.

The AHRQ, who commissioned the report to be done, had this to say,

“The Institute of Medicine study provides the clear evidence to prove what we have long-believed is true—fatigue increases the chance for human error,” said AHRQ Director Carolyn M. Clancy, M.D. “Most importantly, this report provides solid recommendations that can improve patient safety, as well as increase the quality of the resident training experience.”

As can be imagined, not all physician groups are cheering, the American Association of Neurological Surgeons came out with a strong statement against the panel’s recommendation. There are three main arguments against resident work hour restrictions.

First, while resident fatigue promotes errors so do “hand offs.” Hand offs occur when you turn care of a patient from one resident to another. As you can imagine, restricting resident work hours increases the number of hand offs. By some estimations the panel did not adequately weigh such risks to patients.

“The IOM committee, in making these recommendations, has failed to adequately consider the key patient safety issues – the considerable risks associated with too many patient handoffs and lack of continuity of care in complex neurosurgical disease or injury cases,” remarked AANS President James R. Bean, MD.

The IOM report was published just months after a major study published by the Joint Commission. This study, done at MGH, found that,

A significant percentage of resident physicians report that patient handoffs – transfer of responsibility for a hospitalized patient from one resident to another – contributed to incidents in which harm was done to patients. The study, published in the October 2008 Joint Commission Journal on Quality and Patient Safety, identifies situations in which problematic handoffs are more likely to occur and factors that may interfere with the smooth transfer of crucial information.

“Our findings suggest that patient harm from problematic handoffs is common,” says Barry Kitch, MD, MPH, of the Massachusetts General Hosptal (MGH) Institute for Health Policy and Harvard Medical School (HMS), lead author of the study. “In fact, problematic handoffs may be as significant a source of serious patient harm as are medication-related events.”

Second, the changes will limit the experience resident physicians get. In complicated surgical fields such can be an actual detriment to future patient care. Neurosurgery residency, for instance, is already up to eight years in length. There is nowhere to go to extend the length of time you spend in residency. And so neurosurgery residents are literally getting less training than before the work hour restrictions, as the AANS/CNS/SNS press report points out,

Additional restrictions in resident work hours will also create a new generation of surgeons with reduced surgical experience and expertise due to less exposure to complex surgical cases and direct patient care. “Unless the residency training period is extended considerably, residents in neurosurgery will receive 25 to 50 percent less training than residents received prior to 2003,” stated M. Sean Grady, MD, Charles Harrison Frazier Professor and Chairman, Department of Neurosurgery, University of Pennsylvania and current ABNS chairman. “One could reasonably ask whether any patient would choose to be treated by a neurosurgeon who receives half the training of today’s practitioners.”

Third, residents are cheap labor. That’s just honesty. Plenty of teaching hospitals in part actually need residents to make the system work. These are, often, full fledged physicians working at a fraction of their real earning potential to further their training. They’re cheap. Restricting their hours can significantly raise the costs of health care. Back to the New York Times piece,

“We know there is a cost to this,” said Brian W. Lindberg, a panel member and executive director of the Consumer Coalition for Quality Health Care in Washington. “If we’re enabling residents to have sufficient sleep, someone has to cover care during those periods. We also believe if you look at the totality of the recommendations, there is the potential for efficiencies in the system and savings from reduction in errors and harms. In the long run, it won’t cost as much as one might estimate.”

Plenty of other stakeholders, besides those groups representing neurosurgery, think the IOM has jumped the gun. The American Association of Medical Colleges tip toed around the issue but had this little rebuke for the report,

If the current duty hour limits are modified, it will be important to consider the impact of potential changes on other members of health care teams and the effect on patient care.

Putting the 2003 ACGME standards into practice has been a complex undertaking. The planning and implementation of any further changes will require significant time and resources.

The Institute of Medicine report holds no force of rule. Instead it is a recommendation for the actual self governors of medicine, namely the ACGME, to change the rules. Let’s hope that the ACGME is smart enough to simply ignore it.

Tuesday, December 2nd 2008

Grand Rounds at Mexico Medical Student

Mexico Medical Student has put together a great edition of Grand Rounds this week. I’ll let Enrico explain his theme, which is very cool.

Welcome to Grand Rounds! I am privileged to be your host for this week’s edition of the best posts of the medical blogosphere. As in the previous two times I’ve hosted, I will integrate music into this edition, but unlike before, I will focus on one piece of music: Tod und Verklärung (Death and Transfiguration) by the German composer Richard Strauss.

Death and Transfiguration is a “tone poem,” literally, a musical literary depiction. In this case, it is of a dying artist on his deathbed in his last moments, and what is experienced up to, including and after death.

And he takes it from there, weaving in the best the medical blogosphere has to offer. Go check it out.