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Archive for April, 2012

Thursday, April 19th 2012

Independence & Efficiency of Communication


Not That I’ve Ever Worked 40 Hours

It’s my opinion from limited, but not undiverse, observation that at public teaching hospitals resident physicians are burdened with an unnecessary number of mundane calls and often at inapropriate times. This compared to the private world.

I’m not sure why there needs to be a 11pm call for a potassium of 3.7 or a 2am call that there is no order for incentive spirometry. Not that such inappropriately timed communication is limited to nursing staff. I’m not sure why a resident (or staff) radiologist needs to call the ordering physician at midnight that an NG tube is in the esophagus. Nor am I excused here. I’m not sure I need to call the medicine consult service at 10pm for asymptomatic hypertension.

It seems sometimes that individuals within teaching facilities operate with very poor levels of discretion and independence and just plain commonsense.

My residency program rotates through my faculty’s private practice at a facility with no other residents. Similiarly my wife started at a community program where her residency was the only training program within the system. The norm in these private institutions is far fewer of such calls in my experience. Not that they don’t happen, just that they’re with much, much less frequency. Instead you arrive in the ICU for morning rounds and the nurse informs you, “The patient’s nausea was well controlled and she passed her bedside swallow last night so I pulled her NG tube and advanced her diet. Can you sign those orders in the chart?”

There is something in the culture or training of public teaching hospitals which apparently encourages everyone to run everything by everyone else. There is limited initiative and limited recognition of which issues need to be tertiarized to someone higher up.

I think the fact these institutions are places of training, and not just physicians but nurses and other providers, makes for more calls as people learn. I think the fact more providers take call in house at large public hospitals encourages calls as there is an attitude that the resident physicians are already working and so there is hassle to calling. I think the fact that these hospitals take care of sicker patients, who probably require more calls in general, encourages frivolous calls. And I do think that the fact it is residents, and not private physicians, who are being called also lowers the threshold at which calls are made somewhat.

Now to be fair my exposure to large public teahcing facilities outside my own is limited. I have some at rotations as a medical student and remember residents at those places getting plenty of inappropriately timed calls but perhaps my experience isn’t representative. I’d be interested in hearing from those who have been at other places.

This issue isn’t merely a matter of resident lifestyle; although it is such. This is a patient care matter. A call from a radiologist about a malpositioned Donhoff tube probably shouldn’t go from the radiologist to the ordering physician to the nurse, it should go from the radiologist to the nurse who understands the correct position and advances the tube of his own initiative. Increasing the relays of information is usually poor design, no less in health care. Nurses and RTs and other providers who can correctly tertiarize issues and provide appropriate care to patients on the spot obviously represents a better model and better patient care than waiting for a verbal order, from a scatterbrained resident in the middle of the night.

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Wednesday, April 18th 2012

The Costs of Defending A Malpractice Claim

Claims of malpractice against physicians, even claims that do not lead to payments to the plantiff, implying some level of evidence for the physicians’ care end in significant cost for defense.

[A]lthough the costs of dispute resolution are higher for claims that result in indemnity payments, there is still a meaningful cost of resolving claims that never result in payment

The median cost for claims in this study with no indemnity payment was $22959. To be fair these are costs borne largely by the insurers and not by the providers themselves but not doubt it contributes some small amount to the costs of healthcare.

It is true even factoring in defense costs and the costs of defensive medicine the contribution of our messed up malpractice system to total healthcare costs is not what most American physicians imagine it.

But that fact shouldn’t lower malpractice reform on our agenda. It isn’t solely a matter of costs but a matter of justice. A reform of the specialty malpractice system should include specialty courts and those courts and systems for mediation should have the power to force the plantiffs, not just in frivolous cases but in all unsuccessful cases, to make the plantiffs take on some or all of the defense costs.

I know that would discourage legitimate malpractice suits but considering the costs in defense, especially the costs of claims that do not lead to payment, I think such would be an important reform.

Tuesday, April 17th 2012

Subrachnoid Hemorrhage

What is the most common cause of subarachnoid hemorrhage?

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