Anger management for doctors

A recent Washington Post/Kaiser Health News story about anger management led with an anecdote about a surgeon who broke a scrub tech's finger by slamming down an improperly loaded instrument. The surgeon was suspended for two weeks and had to take an anger management course, which seems like a mighty small penalty for what could be described as assault.

But the story had to go where many such tales seem to go these days.

Here's a quote: "Experts estimate that 3 to 5 percent of physicians engage in such behavior, berating nurses who call them in the middle of the night about a patient, flinging scalpels at trainees who aren't moving fast enough, demeaning co-workers they consider incompetent or cutting off patients who ask a lot of questions."

Demeaning co-workers and berating nurses who call in the middle of the night? Yes, these things unfortunately do occur. But "flinging scalpels at trainees"? Sorry, I don't think so. But of course, exaggeration is a common feature of articles about doctors, especially if the story wants to portray us in a negative way.

I was a surgical chairman for many years. I know all about disruptive doctors. In a recent blog, I even admitted to throwing an instrument myself once when I was a young and headstrong resident.

A link in the Washington Post story goes to a full text paper on disruptive behavior in the Journal of Medical Regulation (who knew there was such a journal?). The author points out that isolated episodes of what some might consider bad behavior can happen, but unless there is a pattern or the incident was egregious, doctors should not be labeled as disruptive.

There are many problems with disciplining disruptive physicians. The article addressed a few of them. 

Here are a couple that weren't mentioned. 

The disruptive doctor may be a busy surgeon or big admitter of patients. This puts the hospital in a bind, especially if there are other hospitals nearby. The doctor can and will threaten to take his patients across town. 

Or the bad actor may be the only physician in a critically important specialty on staff. 

These situations give physician miscreants leverage which tends to mitigate the punishment meted out—analogous to the way pampered athletes and movie stars are treated when they commit crimes.

I have first-hand experience with this having dealt with disruptive surgeons in the past. What I wanted to do and what the hospital administration would permit me to do weren't always the same. By the way, behavior modification programs rarely result in permanent cures. A middle-aged surgical ogre is not likely to become Prince Charming after two weeks of anger management.

So the issue is not as straightforward as it seems. 

By the way, just to show how far toward equality we have come, that surgeon who broke the scrub tech's finger was a woman.

More problems with patient satisfaction surveys

Here are some updates on the patient satisfaction front.

A paper in last month's JAMA Surgery journal noted that patient satisfaction ratings have very little to do with the quality of care provided by a hospital.

The study analyzed data from 31 hospitals that were participated in patient satisfaction surveys, the CMS Surgical Care Improvement Project (SCIP) and employee safety attitudes questionnaires. 

They found that patient satisfaction did not correlate at all with the rates of hospital compliance with SCIP process measures or the opinions of employees about the culture of the institution for half of the categories questioned.

They concluded that "patient satisfaction may provide information about a hospital's ability to provide good service as a part of the patient experience; however, further study is needed before it is applied widely to surgeons as a quality indicator."

What about patient satisfaction and the quality of medical care provided by doctors? 

This is only an anecdote but it does say volumes about the subject.

A New York area cardiologist admitted to defrauding government and private insurers of $19 million. This was described as the largest healthcare scam by a single physician ever recorded in New York or New Jersey. 

Thousands of patients underwent unnecessary and possibly dangerous tests and treatments. He also employed unlicensed and unqualified personnel who treated patients.

As noted by Dan Diamond, managing editor of the Daily Briefing, the Healthgrades patient satisfaction scores for Dr. Katz all ranged from very good to excellent.

In fact, Dr. Katz has received not one, not two, but three Healthgrades Quality Awards, which are still in evidence on their website. I guess $19 million worth of fraud is not enough to impact one's Healthgrades ratings.

Although this next vignette is about customer satisfaction and has nothing to do with patients, it too illustrates the folly of basing one's opinion on satisfaction scores alone.

According to the Consumerist blog, an subsidiary of the magazine Consumer Reports, certain well-known companies have based employee pay raises and promotions on the results of customer satisfaction surveys.

Apparently, the companies considered anything less than a perfect "5" rating as failure. This resulted in employees telling patrons to either give them a "5" rating or if they could not do so, decline to take the survey. 

I have seen this phenomenon in hospitals too. Staff were coached about what to say to patients to help persuade them to give higher scores. 

I think it's called "gaming the system."

For lots more on the subject, type "patient satisfaction" in my blog's search field (upper right corner).

ADDENDUM 5/9/2013

A friend emailed me this comment: "When I take my car to the dealer for service, they tell me they will be sending me a survey in the mail. Then they tell me if I cant give them all '5's, I shouldn’t fill out the survey, instead I should call them and speak to the manager so they can do better next time"

What goes on at a real morbidity and mortality conference?

f you’ve read my reviews of the new medical TV show “Monday Mornings” [here, here and here], you’ll know I’ve been critical of many things about it. I was particularly disappointed with the way the show handled one of its central themes—the morbidity and mortality (M&M) conference.

I thought it might be useful to tell you how most real M&M conferences are run. M&M conferences generally take place at hospitals with residency training programs and are rather specific to surgical disciplines.

It is possible that they may be held in large non-teaching hospitals, but time constraints and the fact that direct attending surgeon to attending surgeon criticism in an open forum is difficult to do.

Unlike the TV version, real M&M conferences feature presentations by residents, not the attending staff. The resident who performed the operation prepares a summary of the case which these days is usually on PowerPoint. Pertinent history, physical exam findings, lab results and images are shown. A radiologist or pathologist may be on hand to help educate the attendees. The conduct of the surgical procedure and the patient's hospital course are described.

The resident is asked questions about the way the case was managed and what she knows about the disease process and the surgical literature. The resident may have prepared a brief review of recent papers on the subject.

The attending surgeon who was involved with the case might add some more details. At least one person asks a question that was already addressed in the presentation. An attending surgeon or two will describe a similar case they had 10 years ago that went wrong and state that now he does things a different way, never mind the evidence to the contrary.

Comments from other surgeons and the chairman are made. Often a consensus may be reached about whether or not the complication or death was preventable. The idea is that the discussion informs the whole department, and everyone does not have to make the same mistake. In theory, the complication might be averted the next time.

However, not all complications or deaths are due to errors. Sometimes despite everything being done correctly, outcomes are bad.

In the old days, residents were blamed for everything that went wrong. Public humiliation was common. A famous chairman allegedly once said to a resident who presented a case that resulted in a patient's death, “Why didn’t you just take a gun and shoot him?”

Although this is said to still happen in some hospitals, the conference is much more civil in most places.

Unlike the “Monday Mornings” version, M&M conference is not where attending surgeons are browbeaten, tricked or fired. Of course, the real conference is far less dramatic (most of the time).

There can be raised voices and sometimes arguments occur, but the focus of the conference is usually more on education and quality improvement.

It's too bad about the show. It could have done a lot of good if it tried to realistically portray how self-critical we are. Unfortunately, it went all Hollywood on us, like every other medical TV show.

Why won't the AMA stop asking me to pay dues?

Today I received another one of these in the mail.

It's a dues notice from the American Medical Association. For a mere $420.00 per year, I can become a member. 

Over 10 years ago, I dropped out of the AMA because it seemed to be run by a bunch of old guys who were out of touch with the real issues of practicing medicine in the 21st century. Other than the included subscription to a journal which was then called Archives of Surgery, I felt that I received no value from belonging.

Approximately every 3 months since then I have received notices like the one above from the organization.

By now, you would think they might have a clue that I am not interested in rejoining, but the notices keep on coming. I realize the process is probably automated and the algorithm doesn't sense the fact that I'm never going to respond. But here's a thought.

There's a scheme that some magazines run. They send you a "free" copy and if you don't read the fine print, you get one every month. Then you get a bill.

A variation is this. Figuring that your address is a business which is quite likely when someone is an MD, magazines send frequent subscription "renewal" notices when you've decided to discontinue it or even when no prior subscription exists. What they are hoping for is that an office manager or secretary will see the notice and pay the bill as a matter of routine. 

To illustrate this note that I also discontinued my subscription to the New England Journal of Medicine a few years ago, but every two months I get a renewal notice as if I had been a subscriber all along.

I'm not saying I can prove that the AMA is doing this with the same intent, but why would they keep it up for so long?

Also, I wonder how much money they waste mailing these notices.

According to recent figures, only about 17% (217,000) of all US doctors and medical students are AMA members, 25% of them are over 65 years old and enrollment is flat. 

I'm not sure why anyone belongs. Any ideas?

Attorneys and physicians share common goals?

Here is big news from the March 2013 issue of the American College of Surgeons Bulletin.

 

The headline reads, "Attorneys and physicians share common goals." 

The primary author is a medical liability plaintiff's lawyer from Washington, DC. 

The article states that surgeons and liability attorneys want similar things for patients. "Both surgeons and patient attorneys are committed to patient well-being and the relief of patient suffering." Really? So for liability attorneys, it's not about the money? I see; it's about "relief of patient suffering."

"Surgeons belong to an ancient and esteemed profession; every day, surgeons cure disease, relieve pain, and make lives better. Attorneys see themselves as members of another healing profession, helping to restore to broken lives some measure of independence and dignity." I did not know that attorneys were members of another healing profession. I've never heard it put that way before. I mistakenly assumed it might be about the money.

"When injured patients are treated fairly in the legal system, it helps restore their trust by facilitating communication between the clinician and the patient and providing clarity about a potential error and how it occurred." So the elaborate process that goes along with a medical liability lawsuit is all about communication and restoring trust? And I thought it was about the money.

"Liability cases and fair compensation are means of honoring patients. Because they draw attention to patient suffering and physician error, they help ensure that the opportunity to prevent harm to another patient will not be lost or wasted." It's good to know that plaintiff's attorneys are in business for the purpose of honoring patients. Silly, cynical me. I thought it was about the money.

"In the U.S., the 'deny and defend' response from physicians is quite common. This reaction may be due in part to the perverse and dangerous incentives that characterize the American medical system. For instance, the fee-for-service model provides a disincentive for less-qualified surgeons to refer patients to trained specialists." According to Mr. Malone, doctors' denying and defending lawsuits is the real problem. And that's because of the fee-for-service payment system? Sorry, I don't follow that line of reasoning.

"One legal reform could go a long way toward fixing this problem. If surgeons were employees of their hospitals and not independent contractors, the employer would have both the muscle and the financial motivation to better supervise individual practitioners." Mr. Malone may have a point here, but I wonder if he would opt for a system that made all lawyers employees and not independent contractors? Since we are both members of healing professions, I think it would be fair if everyone was salaried.

Regarding the use of guidelines as a malpractice defense which some have labeled a "safe harbor," he says, "However, the safe harbor concept becomes unacceptable if it allows guidelines to be used as a 'get out of jail free' card. Guidelines must be useful in exonerating and implicating clinician wrongdoing." What he seems to be saying is that it's OK to use a guideline to prove a clinician did wrong, but following guidelines shouldn't be a fail-safe defense strategy.

Maybe someone can explain to me why the American College of Surgeons would print an article such as this in its house journal.

Do BSN nurses provide better care?

A paper entitled "An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality" appeared in Health Affairs in March and  generated quite a lot of buzz on the Internet.

Its major finding was that hospitals in Pennsylvania that had 10% more nurses with BSN degrees were found to have 2.12 fewer deaths per 1000 postop patients than those that did not. The authors extrapolated this, saying that if all the hospitals they surveyed had the same percentage of BSN nurses as the best performers, 500 deaths may have been avoided.

The reduction in mortality rates was not significantly affected by staffing levels, skill mix or years of experience as a nurse.

The mechanism for the decrease in death rates was not explained but assumed to be better rates of "rescue" after the development of complications which also was significantly associated with the presence of more BSN nurses and not staffing levels, skill mix or years of experience as a nurse.

The abstract concludes, "The findings provide support for efforts to increase the production and employment of baccalaureate nurses."

The math in the paper is confusing. In 2006, 25,000 nurses responded and 1/3 (presumably about 8,333) of them were staff nurses in general hospitals. The information from those 8,333 nurses was the basis of the study. They go on to say that there were 134 hospitals with an average of 48 respondents. That computes to 6,432. That's a discrepancy of over 2000.

A cliché that is often used in comments about research papers is "the study raises more questions than it answers."

Here are a few. 

Could it be that the hospitals with improved mortality and rescue rates are simply better hospitals? And maybe BSN nurses are simply more likely to work at better hospitals. 

If 2/3 of the nurses who responded to the surveys are not working as staff nurses in general hospitals, just what are they doing? Going to committee meetings?

A nurse who commented on a recent post of mine about a national organization setting up a "Transition to Practice" fellowship for graduating surgical trainees who lack confidence in their skills said,

I could say the same about nursing school. Why are there suddenly nurse residencies and nurse fellowships? Because there is too little clinical time while in school. My nursing school has a name that you would recognize. Our med-surg clinical days were one half-day per week spent at the hospital, about 26 in total over 2 semesters. Peds and maternity, about 5 half-days each. I was lucky because I was on a general medicine unit and got to see a variety of patients. We all complained that our clinical time was inadequate. The preceptorship in the last semester consists of working eight shifts one-to-one with a staff RN. No wonder, then, that hospitals are not confident in the capability of new nurses to practice safely and effectively.

Why is it that over 100 hospitals have established "nursing residency" programs? Click here to see a list of them published by the University of Pennsylvania. 

Here are quotes from two hospital websites about their nursing residency programs.

The Nurse Residency Program at Mayo Clinic in Arizona is a full-time registered nurse position with a one-year orientation program that assists you in transitioning from a new graduate to a fully competent, professional nurse at Mayo Clinic.

Children’s National Medical Center’s Pediatric Nurse Residency program provides the novice nurse with the knowledge base and skill set needed to transition to competence in clinical nursing practice.

What they are saying is that at least some graduating nurses are not competent. This meshes well with recent findings that graduating surgical residents are not ready to practice independently.

Why can't we teach nurses how to nurse in school and docs how to doctor during residency?.