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Archive for September, 2010

Thursday, September 23rd 2010

The Fear of Social Media

The intersection of social media and privacy has made an older generation, and even some of my own generation, incredibly uncomfortable. There is talk of present and future consequences. Lost jobs, lost income, civil judgments, loss of respect/embarrassment, even criminal penalties for all that you put online. There is an idea that the blurring of intimate boundaries will come back and bite a whole generation.

Being online has responsibilities and consequences, no doubt. But Facebook isn’t going to cost most people a future job or a future election. The social rules are, as we speak, changing in terms of how we judge people for their private lives that they make public. The whole world is using social media and putting themselves out there. Tough to judge someone for your same acts.

That said, if there’s one place there is legitimate consternation over social media it is in health care.

Because those involved in health care and social media have the often near unique oppurutinities to not only dismiss their own privacy online but to do so for others. Horrific stories are rife. Take this one for example,

William Wells arrived at the emergency room at St. Mary Medical Center in Long Beach on April 9 mortally wounded. The 60-year-old had been stabbed more than a dozen times by a fellow nursing home resident, his throat slashed so savagely he was almost decapitated.

Instead of focusing on treating him, an employee said, St. Mary nurses and other hospital staff did the unthinkable: They snapped photos of the dying man and posted them on Facebook.

It is unfortunate if such scares providers and health systems away from social media like blogs, Facebook and Twitter.

As Ed Bennett comments,

“We already have guidelines; social media is simply another form of communication. It’s no different from e-mail or talking to someone in an elevator,” Bennett said. “The safe advice is to assume anything you put out on a social media site has the potential to be public.”

It’s a form of communication with the potential, as all others, to be abused. But more importantly, it has great potential to further provider-patient discourse and aid in health.

No patient privacy protections will ever be perfect. No patient-provider communication rules will ever absolutely guarantee professionalism and accurate information at all times. But guidelines and rules can limit such problems while furthering patient’s access. That holds no matter the medium.

The proliferation of easy mass communication tools should be embraced by health care, not cowered from. As always there are appropriate and inappropriate uses which health care providers should be counseled on and which should carry rewards and penalties. But just because social media is new shouldn’t make it scary.

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Monday, September 20th 2010

“Practice”

I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized. Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me.

This from a medical student’s experience, writing over at Mom’s Tinfoil Hat and linked from a longer piece at The Unnecesarean. An alarmist piece.

Medical facilities where training takes place already face somewhat of a stigma. No patient wants to be a “guinea pig.” Certainly not in the dramatic examples given of non-consensual invasive pelvic exams.

But for every anecdote given there is the opposite. I have never seen nor heard in the number of places I’ve done rotations, of medical students doing pelvic exams on patients under anesthesia without those patient’s permission. Anecdotes like the above scare off patients from teaching facilities. Such is a shame.

Teaching facilities provide an unparalleled level of integrated, multi-specialty care. It features physicians who are often leaders in their field. It often offers a team of physicians, students and others who can afford the time and focus that patients deserve.

The horrors that can befall patients are not limited to an academic setting and so I hate to see anecdotes like above go unchallenged.

Sunday, September 12th 2010

The Downside of EMR

I love electronic health records. To be honest I don’t know how physicians functioned before them. Imagine having results coming back on 10 patients at various points throughout the day and not getting to any of it until the next day. I’m sure it was functional, if less efficient.

But there’s a downside. Namely when the EMR system goes down, it’s not like the entire health care organization returns fluently to the good ol’ days of paper records and reporting. At least in my experience.

A couple of weeks ago the county hospital that is my primary training ground shut down the EMR system in it’s entirety for 24-hours of maintenance and upgrades. The time I spent tracking down labs, talking to the radiologists (when everyone else is trying to), having to haul myself to the actual nursing stations of the 6 different floors my patients were on to put in orders was painful. So is the fact that the half dozen consult notes I hand wrote are essentially lost forever. Nevermind the fact that when faced with the time constraints of a busy weekend on call my notes on paper became decidedly less detailed; which is probably never a good thing.

That said, except for scheduled outages, the EMR systems I have worked with have had decidedly few ‘hiccups’.

I love electronic records and order systems and PACS.

Friday, September 10th 2010

Justice & Malpractice

You should go read Dr. Mello and his team’s new review of the cost of the current medical malpractice system. And then the criticism of such over at The Health Care Blog.

The most important component of malpractice costs is defensive medicine. The Harvard authors put this at $46 billion, or nearly 80 percent of the total, but this is pure guesswork. Researchers cannot agree on the extent of defensive medicine. The Harvard authors base their estimates on seminal studies by Kessler and McClellan. Their work is seminal largely because it was first, not because it was definitive, and later studies often find far less evidence of defensive practice. The Harvard authors try to be conservative by using the low end of the Kessler/McClellan cost estimates. But truth would have been better served if they had stated that the cost of defensive medicine could just as easily be $16 billion or $76 billion.

Dr. Dranove, writing at THCB, has some fine points. As he says any full evaluation of tort reform must consider not only what it may save in medical costs but what it may do to the quality of medical care delivered.

What we need now is evidence on how tort reform affects quality. Until we get that evidence, all the hullabaloo about the new Health Affairs study is really much ado about nothing.

An important consideration, to be sure. I think there’s another factor. How competent at justice the current medical malpractice system is. To be sure, the belief amongst providers is that the rare claim that goes to a jury trial routinely goes against the physician. The evidence over jury verdicts and settlements in malpractice claims clearly shows that they favor the provider. But such isn’t necessarily justice.

80% of verdicts for the defendant in cases of poor outcomes after poor care is unacceptable. So is 20% of verdicts for the plantiff in cases where the level of care should never be classified as malpractice.

Malpractice reform should not only seek to improve quality and lower costs but, just as importantly, make the system more just.

Thursday, September 9th 2010

A Rocket Scientist Speaks

I am a rocket scientist. The one thing people always fail to understand about my job is that rocket science is, in fact, quite simple. The laws of physics that govern the behavior of rockets have been known for centuries, and are really not that complicated. So, next time you consider using the phrase “it ain’t rocket science”, please consider substituting “it ain’t brain surgery” instead. I’ve never met a brain surgeon, but I imagine that that job really is as complicated as it sounds.

The above from The Daily Dish.

My college roommate was an aerospace engineering student, I became a neurosurgeon. Good combo for conversation. But in reality I imagine neither is as difficult as their mythos makes them out to be.

Thursday, September 9th 2010

Brain Surgery Bootcamp

Sanjay Gupta looks at a “bootcamp” put on for neurosurgical interns by the Society of Neurological Surgeons. I went to one of these this year and thought it was very well produced, very relevant and just generally a very good program. I hope the SNS and residency programs around the country continue to support this new program.

Monday, September 6th 2010

Day In The Life…

It’s Labor Day and I’ve made some fairly outrageous claims about the workload of a neurosurgical resident of recent. Seems a reasonable time to lay out exactly what a day on call can be like for me and my fellow residents.

To be fair an average experience may be hard to articulate. Different rotations and different days yield different…adventures. Right now I’m on a service that could hardly be called grueling, but I cross cover the county hospital when on call. On the other hand I once had a 24 hour period where I took 28 consults. Which is something considering it is you and the chief resident and that is it.

But I thought I’d give a median weekend on call for me right now hour-by-hour. In reality I cover both a VA and a trauma heavy county hospital while on call over the weekend. But considering this is my last month at the VA and my census at the VA, with consults, runs between 2-7 patients I thought I’d condense it and just show a fairly reasonable work load solely at the county hospital.

I’m presenting this under the shadow of the 30 hour straight rule and the 80 hour work week. I know some older physicians will compare it to their training experience. I know some current or recent residents will point out that their program routinely flaunted the 80 hour rule. So be it.

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