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."

Should radiologists tell patients their test results?

Radiologists discussing test results with patients, a subject that has been lurking under the radar for a while, recently came to light because of an article in the New York Times. The idea is that patient anxiety while waiting to find out a test result could be alleviated by an immediate discussion with a radiologist.

That would be very nice, but there are potential problems, some of which are detailed in a post that appeared on the website of The Advisory Board and others in an editorial by radiologist Saurabh Jha accompanying a paper on the subject..

In the Times, Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford, said, “[T]he radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

My grandson survives a visit to the ED

Last weekend, my 16-month-old grandson was at a backyard barbecue with his parents. He had been eating some potato chips when he suddenly stopped breathing and turned blue.

Having had CPR training, my son started rescue breathing and suspecting aspiration, performed toddler airway clearance maneuvers. No obstruction was found. The child slowly awakened but was very drowsy.

Because of the concern for aspiration, an ambulance was called and the child was taken to the nearest hospital.

My son called and told me what happened. My wife and I drove to the hospital, which was 15 minutes from my home, but not one where I knew any staff.

By the time we arrived, child had been in the ED for about 10 minutes. Two nurses were trying to start an IV in his chubby arm, he was crying loudly. We took that to be a very good sign. He had already been examined by a doctor.

After successfully starting the IV, the nurses secured it and calmed down my daughter-in-law. She asked where she could buy a bottle of water. One of the nurses said not to bother and brought her a glass of ice water.

The nurses were gentle and professional, so much so that my wife, who is a former ED nurse, didn't mention that fact until nearly 5 minutes after we got there.

The initial vital signs taken were remarkable for a temperature of 104° F, prompting the emergency physician to suggest that the child probably had suffered a febrile seizure. He ordered a chest x-ray because of the history of possible aspiration.

The boy stopped crying and began to watch a cartoon on his father's iPhone. Soon he was smiling and laughing.

The x-ray was negative, and the fever came down with ibuprofen. I resisted the strong urge to point out that lowering a child's temperature has never been shown to prevent a febrile seizure.

We were all relieved that he was okay.

If you were expecting a tale of mistakes, sloppy nurses, and arrogant doctors, I am sorry to disappoint you.

Several essays, blog posts, and media articles about poor care received by doctors or their family members have recently appeared.

This is not one of them.

PS: The nurses complimented us for not trying to run the show.

Non-English-speaking patients. Lost in translation?

What is one of the rules that medical people comply with the least?

My vote goes to "translation." The rule is that you must use a qualified medical interpreter for any interview or discussion with a patient who does not understand English.

How is lack of understanding defined? It is usually fairly obvious. If you aren't sure whether the patient gets it, he probably doesn't.

Why can't family members act as translators?

There is no guarantee that they will understand what is said or transmit it accurately to the patient.

What are the options?

You can summon a translator from the list of hospital personnel who have volunteered to translate. This works if the language in question is Spanish or maybe French. It's not often useful for Bengali or for most of the 13 or so national languages spoken in Mali.

The Joint Commission says if hospital employees are used, they must be qualified as translators and suggests ways that they can become qualified such as language proficiency testing, training in the practice of interpreting, interpreting experience in a health care setting and knowledge of medical terminology.

One website I found while researching this subject claims that the Joint Commission says all on-site interpreters must undergo an FBI background check. I could not verify this with the JC because its standards are only available if you pay. [Digression: If this is true, it is very interesting since doctors and nurses do not have to undergo FBI background checks.]

Many hospitals do not have formal training for interpreters nor are interpreters always available around the clock.

Sometimes hospital administrators take things too literally. In one hospital I know of, a fully bilingual surgeon was told he could not obtain an operative consent in Spanish (his native language) because he had not been trained as an interpreter.

There also are times when the hospital employee is not up to the task either because of education or attitude.

A hospital can contract with a service to provide interpreters via telephone. The advantages are that the interpreters are qualified and speak many different languages, far more than you might find among hospital personnel.

Among the disadvantages is the awkward nature of these conversations. If you use only one handset, you have to keep passing the phone back and forth and you can't hear what the interpreter is saying.

A two-handset phone set-up is somewhat better, but you have to find it. It is always stored in a different place on each floor of the hospital.

Accessing the service can be time-consuming. You must make an 800 call, log in, wait for the interpreter to join and so on.

Either in person or by telephone, the conversation can be frustrating.

I have had occasion to say something to the interpreter that took 2 minutes only to have the interpreter talk to the patient for 10 seconds. Here's a video example.

But the real problem is lack of true physician-patient interaction. You are both talking to someone else. Telling a patient she has cancer or what the risks and benefits of a procedure are is often accompanied by stunned silence from the patient. You really can't tell how much has been understood.

Also worth noting is that whatever the language, most of the time we then have the patient sign a consent form that is written in English.

You may have figured this out by now—many hospitals don't do any of this very well.

What do you do with a patient who speaks a language that even the telephone interpreter service doesn't provide?

We simply do the best we can. I'm not sure that any interpreter, phone or in person, can really communicate with some of these patients. 

Now that I think of it, I'm not sure how many English-speaking patients understand us either.

What's the point of medical licensing?

A surgeon emailed me the following (in italics).

OK, I know this is radical but consider my argument...

Medical licensing protects no-one and costs physicians hundreds to thousands of dollars each year. If a physician is negligent, can the injured party sue the state that licensed him? I'm guessing not.

When I moved to my current location, I had to send lots of documentation to the state medical board so they could verify that I was a true and competent surgeon. I provided my employer with the same info so they could also verify my credentials. Now my employer can and will get sued if I commit a negligent act and absolutely should verify my credentials prior to handing me a scalpel. But the state? It's license is useless.

Most people choose a surgeon based on recommendations and word of mouth reputation and these are by far better indicators of quality than any credentialing board. Nobody asks to see my license, and, even if they did, it would not protect them any more than their trust in the health system in which I work.

If I was in private practice and had my license displayed on my wall it may give some reassurance to my patients, but it does not say anything about the quality of my work. Most doctors who really screw up due to negligence are licensed by the state.

I contend again, that word of mouth and reputation are the best indicators of a surgeons ability, anything beyond that is useless.

Caveat emptor, "let the buyer beware" remains the mantra of the informed consumer.

Thanks for letting me vent.

Of course this is a bit of exaggeration to make a point. We obviously need some sort of medical licensing or the public would not know if we were the same as the "butt enhancement" people who operate out of motel rooms.

But it's true that we—doctors and the public—don't get much bang for our buck. As I mentioned in my post about the Texas neurosurgeon who ran amok before that state's medical board took action, licensing fees are generally used by most states as a type of tax.

For example in the state of Texas, only$11 million of the $40 million in licensing fees collected per year goes to the medical board for policing the profession. The rest is left in the state's general fund.

My state also uses medical licensing fees as a tax rather than as a means to run a more effective medical board. I wonder how many other states do the same thing?

It's interesting that the surgeon who sent me this email has the same recommendation found by a researcher who recently looked at the relationship between hospital quality and patient satisfaction. Like many others, he found that there is no such relationship.

As the article about that paper states, "He [the researcher] suggested choosing a hospital the old-fashioned way: find a doctor you trust and ask for a recommendation."

PS: I'm surprised that lawyers haven't thought of suing states for allowing bad doctors to keep licenses.

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"

Patient satisfaction and reality

Christmas came early for us skeptics this year. In a landmark study, certainly one of the most interesting and thought-provoking of the year-to-date, researchers from the University of California-Davis found that the more satisfied patients were with their physicians, the higher their hospital admission rates, prescription costs and total costs were. And patients with the highest level of satisfaction with their doctors had higher mortality rates compared to those patients least satisfied with their doctors.

The prospective cohort study included almost 52,000 patients. The full text of the paper can be viewed here. I won’t bore you with the details of how it was done except to say it looks scientifically legitimate.

The study’s authors say, “Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations. Patient requests have also been shown to have a powerful influence on physician prescribing behavior, and our findings suggest that patient satisfaction may be particularly strongly linked with prescription drug expenditures.”

Translation. What they mean is that doctors who do what their patients want receive higher satisfaction scores. This may also include admitting patients sooner rather than later, which could account for the fact that patients who were more satisfied had lower rates of emergency department visits.

So it seems patient satisfaction may not be the great “quality metric” that it is touted to be. The study concludes, “an overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes.”

Due to something called "copyright law," I will resist the urge to quote the whole paper. I suggest you read it and judge for yourself.

More on Patients and “Shared Decision Making”

About 10 days ago I tweeted this, "How can a patient, who does not know what meds she is on or why, seriously participate in 'Shared Decision Making'"

After receiving several negative comments about the tweet, I blogged in detail about patients not knowing what meds they were taking and finished with this:

“While I’m on shared decision making, I have this final comment. Physicians should not present three options with lengthy dissertations on the myriad side effects of treatment and no real advice as to what would be best for the patient. You cannot teach someone the anatomy, physiology or the nuances of medical care in a shared decision making discussion, especially if that patient can’t even remember what his meds are.”

Thanks to MedPage Today’s rather indirect mention of a poll involving patients and my superior internet research skills, I discovered this recent study from the Journal of Medical Ethics. Investigators at the University of Chicago surveyed 8308 hospitalized internal medicine patients and found that after hearing their options and being offered choices, 67% preferred to leave medical decisions to their doctor.

As I said before, I always review the options with a patient, listen to their concerns and answer their questions. But as the majority of patients themselves believe, I think I am in the best position to recommend the appropriate treatment. Maybe a better term than “shared decision making” would be “shared information.”

More on Why Patient Satisfaction Surveys Are Useless

Patient satisfaction surveys are theoretically good things. After all, hospitals and doctors should know what their patients think about them. If a service is not performing well, the results of a patient satisfaction survey would be useful to help us make improvements. This would be true if patient satisfaction could be measured in a meaningful way. In a previous blog, I explained some of the statistical problems with all patient satisfaction surveys.

Here’s an example of the current state of the art and why it is useless.

A hospital posted the above graphic. As provided by a leading company, it shows the trend of patient satisfaction scores for the question “Were you informed about the causes of delays during your emergency department [ED] visit?”

You can see that the scores fluctuate around the average score for a year of the 79^th percentile, meaning that 21% of comparator hospitals fared better on this question.

This ED receives over 25,000 visits per year or over 2000 visits per month. The number of responses to the survey questionnaires sent ranged from a low of 2 in June of 2011 to a high of 42 in October of 2010. This represents a range of 0.1% to 2.1% of all ED visits, far below what even a non-statistician would recognize as a reasonable sample.

Despite efforts to improve scores for this question, no significant change has occurred. What does it all mean? If you look at the trend line, you will note that it mirrors what occurs in a feedback loop. [Digression: A thermostat is a classic example of a feedback loop in action. If you set the thermostat for 70 degrees, the temperature will fluctuate about that point. Most of the time it will not be 70 degrees in the room as the furnace will run until the temperature is 70 and when the furnace shuts off the temperature will overshoot. Likewise when the temperature falls below 70, it will take time for the furnace to warm the room back up. (Ref. GJS Wilde, Target Risk 2, PDE Publications, Toronto 2001)] This feedback loop phenomenon is a classic reaction to the posting of such scores. When the scores fall, task forces are formed and meetings are held. A slight improvement is often seen. [Hawthorne effect: performance improves when subjects are aware they are being watched.] But once the scores improve, everyone goes back to business as usual and the scores drop again.

It’s too bad that the 87.5 percentile score was achieved when the response to the questionnaire was a mere 2 patients.

If I were a betting man, I would bet the ranch that the score for this question will be lower for July.