Tuesday, March 31, 2015

Medicine, like air travel, once was fun

A Wall Street Journal blog about a reunion of employees of American Airlines lamented the good old days of air travel. Here's an excerpt:

"They came together to celebrate the days when flight attendants in white gloves hustled to serve you, gate agents doled out upgrades and arranged seating so families could be together, and managers worked flights with the single mission of ensuring excellent customer service."

The employees told tales of the fun they had and the camaraderie they shared. The passengers had fun too.

One retiree said of today's airline employees, "They don't look like they are having any fun at all."

Certainly the same can be said of today's passengers.

I'm usually not a fan of the airline-medicine analogy, but I'm going to make an exception here.

Back in the day, those of us in medicine had fun too. Don't get me wrong. It wasn't at the expense of the patients.

We always approached our patients with a proper attitude of respect. But it was OK to enjoy those encounters and also the fellowship of colleagues. We helped each other out, and we did it with spirit and camaraderie.

Not anymore.

All we read about now is how doctors are burned out, stressed, depressed. We battle with electronic records, hospital administrators, clipboard carriers, third-party payers, the government and just about everyone else.

What happened to the fun? It's all about the money.

David Shaywitz in Forbes: "The view from the front lines suggests that hospitals and care delivery systems are obsessing like never before on doing whatever they possibly can to maximize their revenue. They are consumed, utterly consumed, by this objective."

He added: "Many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago. Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience."

I believe what Shaywitz said is true. Can anything be done or is it hopeless?

Saturday, March 28, 2015

Follow-up: Meaningful Use Stage 3 is coming

Yesterday, I posted "Meaningful Use Stage 3 Is Coming: Should Be Fun" which discussed some onerous new rules that Stage 3 will impose including this one:

More than 25% of patients seen by an eligible professional (EP) or discharged from a hospital or emergency department (ED) must "actively engage" with their electronic health records (EHRs).

I said that in my experience most of the patients I took care of would have been unlikely to engage their EHRs and expressed concern that physicians would be penalized for their patients not reaching the 25% threshold.

A reader commented that the VA has had a patient portal called the Blue Button since 2010. He pointed out that in May of 2012, more than 500,000 unique patients had accessed their EMR. He meant this as a rebuttal to my opinion about the potential level of engagement.

However, it turns out that in 2012 over 6.3 million patients were treated by the VA system.  [See page 4 of this link.] If you divide 1 million by 6.3 million, you get 15.9%.

It seems like they have quite a way to go to get to 25%

I rest my case.

Friday, March 27, 2015

German airliner crash: A system error with a system solution?

From the Associated Press: Airlines around the world on Thursday began requiring two crew members to always be present in the cockpit, after details emerged that the co-pilot of Germanwings Flight 9525 had apparently locked himself in the cockpit and deliberately crashed the plane into the mountains below.

This represents an organization's typical response to a problem. The crash, which by all accounts was caused by a single deranged individual, has been perceived as the result of a “system error” and will be dealt with as such.

The idea that a flight attendant going into the cockpit whenever one of the pilots has to pee will prevent anything seems a bit absurd to me. How is a 5’2” 120 pound female flight attendant supposed to stop a 6’3” 210 pound pilot who is hell-bent on committing suicide by airplane?

When I tweeted a similar thought yesterday, someone suggested that she could simply sound an alarm and unlock the cockpit door. I suppose that’s true as long as the crazed pilot does not punch her in the face and knock her out or shoot her first.

Meaningful Use Stage 3 Is Coming: Should Be Fun

An alert reader tipped me off to something many of you may not be aware of. Stage 3 of Meaningful Use is close at hand.

The "proposed" rules will be officially published on March 30. The good news is that comments will be received for a couple of months.

The bad news is that if the Office of the National Coordinator for Health Information Technology is anything like every other regulatory body I've ever dealt with [e,g., the ACGME's Residency Review Committee for Surgery], the "proposed" rules will be the real rules and the comments will be simply a way for disgruntled physicians to vent.

If you don't believe me about the venting, take a look at the 185 mostly negative comments posted on Medscape’s story about Stage 3.

Here are a few of the new rules that will be in effect by 2017 or sooner.

Tuesday, March 24, 2015

2015 Match Review

Continuing grim news for international med school grads and some US grads too

There were a lot of happy faces on March 20th as depicted in this brief video of the excitement on the campus of the University of Rochester School of Medicine. Similar scenes took place at every US medical school because 93.9% of the 18,025 graduates of US allopathic medical schools matched in a specialty.

But for the 1093 (6.1%) US graduates who didn't match things were not so bright. These applicants had to go through the Supplemental Offer and Acceptance Program (SOAP) which connects unfilled programs with unmatched students.

Because there were over 8600 unmatched graduates from schools all over the world vying for about 1200 unfilled first-year residency positions, even some US med school grads did not secure a position. One of these unfortunate souls tells her story in this blog.

The 7400 or so new MDs left out in the cold will not be able to pursue their careers. They will not progress into any specialty, nor will they be able to obtain licenses to practice medicine anywhere in this country. Those with substantial tuition debt will have no way to pay off their loans.

The percentage of unmatched US graduates has been relatively stable over the last five years, ranging from 4.9% to 6.3% while the number of first-year residency positions offered has steadily increased by nearly 4000 from 23,420 in 2011 to 27,293 this year.

Graduates of osteopathic medical schools didn't fare quite as well. Of the 2949 osteopathic school applicants, 610 (20.7%) went unmatched, but this percentage has steadily declined from a high of 28.3% in 2011.

International med school grads were much worse off; 2354 (46.9%) US citizens and 3725 (50.6%) non-US citizen graduates of international medical schools did not match. Both of these groups also had declining percentages of unmatched applicants. In addition, about 1900 US citizen graduates of offshore schools either withdrew or did not submit a rank list compared to almost 2700 non-US citizen international graduates who did likewise.

Reentering the match next year is an option, but spending a year outside of clinical medicine greatly reduces one's chances of finding an accredited position.

If you factor in the number of applicants who either withdrew from the match for did not submit a rank list. graduates of international medical schools have well below a 50% chance of matching.

In previous posts here and here, I have warned about the risks involved with attending an offshore medical school. If you are considering attending such a school, I urge you to look at the numbers and think long and hard about your decision.

Source: Advance Data Tables 2015 Residency Match

Thursday, March 19, 2015

Patients vs. doctors

A JAMA Viewpoint article suggests that doctors should be aware that patients may be surreptitiously recording their conversations. The author, a neurosurgeon, takes a very benign view of this issue and recommends that if a doctor suspects that patient is recording a conversation, "the physician can express assent, note constructive uses of such recordings, and educate the patient about the privacy rights of other patients so as to avoid any violations."

He also says this would show that the physician was open and strengthen the relationship between the doctor and the patient. I'm not so sure.

Here's a different perspective. If a patient is secretly recording a conversation, the relationship between him and the doctor is already in serious trouble. What I would do is to tell that patient to find another doctor.

If a patient asked me if it was OK to record our conversation, I would agree, but I would also want to record it to preserve a complete copy.

This comes on the heels of another privacy and trust question—should doctors google their patients? There is no consensus on this, but having read several discussions on the topic, most writers feel that googling patients should only be done for certain narrow reasons which you can read here.

Most medical societies have not weighed in on the subject, but I would guess when guidelines are published, they will discourage the practice. But of course, patients may google physicians at will.

Taking it to another level, Dr. Jeremy Brown, Director of the Office of Emergency Care Research at the National Institutes of Health, recently proposed that emergency physicians should be equipped with body cameras to record audio and video of patient encounters.

Leaving aside such questions as who owns the videos, how to store the vast amount of data, and what impact this would have on the performance of the individual physicians, body cameras would establish an adversarial relationship that is unnecessary for the overwhelming majority of doctors and patients.

A physician interaction with a patient begins on terms quite different from those of a police officer interacting with a suspect in which the adversarial relationship is already established. The increasing number of controversial and highly publicized cases involving police and suspects has resulted in a need to protect both parties. This need seems much less pressing in medicine.

Where does this end? Should all patients be equipped with body cameras too in case the physician copy "gets lost"?

It is sad to realize how far we have sunk as a profession.

Wednesday, March 11, 2015

Blame the patient

The other day some cardiologists on Twitter were discussing whether a patient should be blamed if a permanent pacemaker lead became displaced. The consensus seemed to be that it was probably poor placement (i.e., operator error), rather than patient behavior that caused leads to dislodge.

The discussion reminded me of an attending plastic surgeon of mine during my resident days. He was one of the most obsessive-compulsive people I ever met. When he applied a dressing, he always cut the tape with scissors instead of tearing it. He felt that torn tape looked sloppy, and that if a patient saw a ragged edged of torn tape, she might think that the surgical procedure itself had been done without meticulous care too.

When he wrapped a hand, he used a very bulky dressing with yards and yards of carefully cut, not torn, tape over the ace bandage to prevent from slipping or unraveling.

But my favorite eccentricity was what he told patients who had any sort of facial surgery. He had a thing about the role of movement of skin possibly causing scars to separate and permanently widen.

So he gave this written instruction to every patient who had so little as a facial mole removed, "Do not talk or chew for 10 days."

Think about it. Could any patient possibly comply with that? Some of us more cynical types figured that should a scar not have turned out perfectly, the conversation might have gone like this.

Surgeon: "About your scar, you must have talked or chewed during the first 10 days after surgery."
Patient (sheepishly): "Well doc, I must admit I did say a few words, and I had to eat something."

Monday, March 9, 2015

Why I blog and tweet

I have reached a new milestone. My work has been published in a a real journal, the Canadian Journal of Anesthesia. I was asked to write an editorial about social media--"Why I blog and tweet."

If you would like to read it, the full text is available here.