Monthly Archives: September 2013

Nurses Show Us the Way: The Simple Beauty of Connecting in Healthcare

In today’s healthcare environment, we are all driven to see more patients in less time and do more with less support.  Obviously most of this is financially motivated–the delivery of medical care had unfortunately become more of a business than an art.  As more physician groups are now owned by hospital systems, the “bean counters” and administrators are now crafting the rules of engagement.  Physicians no longer have the luxury of time for a leisurely patient visit.  No longer do we have the time to routinely ask about the grandkids and the most recent trip that our favorite patients have taken in their retirement.  Ultimately, it is the patient who suffers.  Those who are ill and those who love them often need more than pills, blood tests, IV fluids and heart monitors–they need support and genuine caring.  These patients and families need a doctor or other healthcare provider  to sit on the edge of the bed and unhurriedly listen to their concerns –to simply chat for a bit.  Unfortunately, this is no longer the norm.  Luckily, we have dedicated caregivers on the front lines in our hospitals who can often fill the gap–nurses.

I was moved last week as I read a wonderful article in the New York Times by Sarah Horstmann.  In the essay, Ms Horstmann (a practicing Registered Nurse) describes her special connection to a few patients and their families on the orthopedic unit in which she works.  Ms Horstman chronicles her struggle with remaining objective and professional in her role as nurse when she becomes emotionally invested in her patients.  She paints a picture of an engaged and caring nurse who is able to put everything on the line for her patients.  Her internal struggles with “crossing the line” in her care for the patient is one that we all as healthcare providers have faced at one time or another.  However, she handles her feelings and her patients with absolute grace.  We can ALL learn a great deal from Ms Horstmann.  We should all strive to feel and care as deeply as she does.  Our patients and the care we will provide them will certainly benefit greatly.

In my experience in medicine, it is the nurses that often lead the way for all of us. I have particular poignant memories from my training of nurses on the hospice care unit at University of Virginia hospital   These nurses set a remarkable example of compassion and connection.  I have been forever impacted by witnessing true caring–crying, grieving and comforting dying patients and their families.

As a whole I have found that many nurses go beyond what the physician is able to do in short encounters.  Nurses spend the time required to get to know the patient–their fears, their thoughts about disease, their thoughts about their own mortality.  Nurses understand family dynamics and can help in managing difficult family situations.  Nurses make sure that above all, the patient comes first–no matter what the consequences.  The very best nurses that I have worked with over the years are ADVOCATES for those who are too scared or too debilitated to advocate for themselves.  Many times early in my career, I did not pay attention or listen to the lessons that were all around me on the hospital wards.  However, as I approach mid-career I am much more attune to these very same lessons that I may have missed earlier.  There is much gained when we watch and listen to others who are caring for the same patient–maybe in a different role–but caring for our common patient nonetheless.  I now realize that nurses have “shown me the way” many times and for that I am truly grateful.

In my opinion, emotional investment and developing patient connections can improve care and assist patients and families with acceptance and with eventual grieving and loss.  I believe developing bonds with patients is a wonderful expression of love for another human being and is completely acceptable in medicine–as long as we are able to remain objective when critical clinical decision making is required. In medicine we strive to provide excellent care for all patients but every now and again there are special patients that we develop emotional bonds with.  Just as in everyday life, there are certain people that you are able to connect with in a spiritual way–whether they are co-workers, colleagues, friends or significant others.  We must stop and appreciate the way in which nurses provide care–we can learn a great deal from them and ultimately provide more “connected” care for our patients.  So, next time you are in the hospital, find a nurse.  He or she will likely be haggard from running from room to room, and it is likely that they have not stopped to eat lunch.  Thank them for caring for our patients.  Thank them for showing us all how to provide better care for our patients.  Then, stop in and say hello to your patient–sit on the edge of the bed and take time to simply just chat.


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Better Health Care for America’s War Heroes: Its Time to Get Serious About Providing Mental Health Services to Veterans

Today I am blogging because I am angry.  Like many Americans, I am saddened by the deaths of twelve innocent people in Washington DC this week.  My emotions have been difficult to reconcile over the last 48 hours.  Often, blogging can be therapeutic for me–today this is particularly true.  Typically, my musings are less than 750 words in length–please forgive me but today I may have to go a bit longer…

The tragic events that occurred at the Naval Shipyard in Washington, DC on Monday have forced all of us to reflect and many of us have begun asking very specific questions:  why did this happen? how could this happen? and, most importantly, could this have been prevented?  As details have emerged, it has become apparent that the alleged gunman Aaron Alexis was suffering from significant mental illness.  The reports of his symptoms suggest psychotic features such as those seen in patients with schizophrenia.  As the investigation continues, it appears that the gunman was a veteran (navy reservist) and had sought mental health counselling and care from the VA hospital system.  Unfortunately, the “system” failed him—failed those who were killed in the Naval Shipyard shooting– and ultimately has failed all of us. Our veterans deserve better.  The VA healthcare system is a proud institution with a rapidly increasing number of patients as the wars of the last 10 years continue to produce ailing servicemen and women in need of care.

Mental health care in the VA system has been identified as a major weakness by those in the VA administrative offices in Washington DC as early as the end of the Iraqi war.  As reported on National Public Radio (NPR) in 2012, the VA has not been keeping up with mental health demands.  In response to the increasing number of veterans entering the mental health system, the inspector general made it a priority to improve mental health services and decrease wait times for veterans requesting help.  In the last five years, the number of veterans requesting mental health services has increased by 33%.  In response, the VA appropriately approved increased funding and beefed up standards for patient evaluation and management.  However, it has become apparent that the ways in which the VA measures itself against a “standard” is rather dysfunctional.

In a hearing in Atlanta in July, 2011, Senator Patty Murray, Chair of the Senate Veteran’s Affiairs Committee, questioned the way in which the VA has been handling mental health care claims.   The Inspector general issued a report and admitted before the Congressional Committee that the VA had skewed the statistics in order to make wait times appear shorter than they really were.

In an opening statement, Senator Murray states:

“In the face of thousands of veterans committing suicide every year, and many more struggling to deal with various mental health issues, it is critically important that we do everything we can to make mental health care more accessible, timely, and impactful.  Any veteran who needs mental health services must be able to get that care rapidly, and as close to home as possible”.

As I mentioned above, during the hearing data was presented that seemed to indicate that most patients were receiving timely mental health care and referrals–the standard is that any patient requesting mental health services is contacted within 24 hours and an appointment is scheduled within 14 days.  However, upon closer inspection, it was determined that the way in which the VA tracked this data was flawed.  They only counted the time until an appointment was scheduled.  Real data from veterans in mental health referral situations shows that the average wait for mental health services in the VA system is actually 50 days.  In some centers (Seattle, for instance) the average wait is nearly 80 days!  Mental health requests will continue to increase as more brave soldiers return from battle.  Those who have served must be afforded with easily accessible, timely healthcare.  Certainly, in the case of naval shipyard shooting suspect Aaron Alexis, better access to more comprehensive mental health care may have made a difference and this week’s tragedy could have been averted.

Senator Murray, after the Atlanta hearings in 2011, issued a summary statement that we should take notice of again today:

“This report confirms what we have long been hearing, that our veterans are waiting far too long to get the mental health care they so desperately need. It is deeply disturbing and demands action from the VA. This report shows the huge gulf between the time VA says it takes to get veterans mental health care and the reality of how long it actually takes veterans to get seen at facilities across the country…this report clearly shows that the VA is failing to meet their own mandates for timeliness. Clearly the VA scheduling system needs a major overhaul.  The VA also needs to get serious about hiring new mental health professionals in every corner of the country.”

The Senator goes on to say  “…the VA is failing many of those who have been brave enough to seek care. It is hard enough to get veterans into the VA system to receive mental health care. Once a veteran takes the step to reach out for help we need to knock down every potential barrier to care”

It is clear that we must do more.  Large agencies such as the VA must eliminate the bundles of red tape that those seeking mental health evaluation and assistance must navigate.  Every single day there are multiple suicides among veterans.  Although money has been allocated for hiring new mental health professionals, a report issued as recently as February 2013 indicated that although roughly 1900 new mental health professional positions have been created, they are not yet filled.  In fact, other previously approved vacant positions have yet to be backfilled.  Our veterans continue to suffer.

When are we going to get serious about providing timely access to mental health services?  Now, more than ever, we have been given a solemn wake up call.  Shall we wait for another mass shooting rampage before we seriously attack the problem?  Do we continue to tolerate those that manipulate data to meet predefined metrics or do we say ENOUGH!  We need action NOW to prevent future tragedies.  The VA system was created to SERVE those who have SERVED.  It is time to live up to that lofty charge and provide prompt mental health care services to those who need it.  Hopefully, with time, those who are grieving losses at the Naval shipyard will heal–lets honor the memory of the fallen by working to provide better mental health services in the US today.

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Big Brother is Watching…And Your Healthcare Privacy Rights May Suffer: More Affordable Care Act Fallout

Data is essential in healthcare delivery and it is often what guides us in improving outcomes.  Utilizing data obtained from large populations helps us better decide what aspects of disease prevention and treatment need more of our attention.  I have shared my concerns about the sanctity and security of these data in a prior blog from July.  These data are important and allow us to evaluate at risk populations and target our interventions.  In the US, participation in surveys is 100% voluntary.  The Centers for Disease Control obtains most of its data from diagnoses reported by healthcare institutions (there are certain disease that are mandated by law to be reported).  However, with the advent of the Affordable Care Act (ACA), some corporations and businesses have taken the acquisition of data a step too far.  In George Orwell’s novel 1984, the author presents a vision of an dystopian society where “Big Brother” watches every move ordinary citizens make in an attempt to maintain order (and advance his own agenda).  We have all seen the recent government abuses within the National Security Administration (NSA) and within the Internal Revenue Service (IRS).  As the ACA is implemented, I am concerned that Big Brother may already be here and working in the US healthcare system today as well.  In medicine, the doctor-patient relationship is sacred–data disclosed for healthcare should be sacred as well.

Although our country has always been based on basic tenets of freedom of choice, right to privacy and other key freedoms, some institutions see Obamacare as a ticket to interfere with the daily lives of American citizens.  For instance as reported in the last several weeks by the New York Times,  Pennsylvania State University now is attempting to require all employees, including senior faculty, to undergo physical exams and answer online health questionnaires that contain very personal and very sensitive health information.  It is obvious that the pressures of the ACA and the need for cost containment is motivating these types of mandates.  From the business standpoint, the university is hoping to reduce risk and liability by modifying at risk behaviors in its insured employees.  However, none of these data will help the faculty do a better job for their employers and I am sure that the Penn State University administration clearly see this as a way to save healthcare dollars.  The next logical step, however, may be to deny or terminate employment based on health risk and potential cost to the system.  Where does the rabbit hole end?  Is this the beginning of health status discrimination in the workplace?

Many senior faculty at Penn State are refusing the mandate based on invasion of privacy–even though the university is planning to levy substantial daily fines for non responders.  Several prominent professors have stated that if they are forced to participate they will simply answer the questionnaires randomly and provide far fetched ridiculous answers–simply play the conscientious objector.  Many other Americans are waiting to see how this pans out–there is concern that this type of activity will begin to spread to other institutions and industries.  Labor unions are already beginning to lobby against these mandates–in the case of Penn State, union employees are exempt.  At what point are our private lives and medical histories private?  What is the separation between workplace and home? Where do we draw the lines and do we allow others (government and employers) to draw the lines for us?

The spirit of risk reduction and working with employees to improve their health status and live better lives makes good sense–however, there are better ways to accomplish this goal.  Health fairs, educational seminars and free health screenings for cholesterol and high blood pressure make good sense–but all of these activities should be voluntary.  Asking highly personal questions such as sexual preference, prior drug or alcohol use and the state of one’s marriage should not be a part of a wellness program at work.  In the case of the Penn State questionnaire there are even questions related to how you get along with others in the workplace–including your boss.  These issues are private and should remain that way. In defense of the institution, the development of these wellness programs are not entirely their fault.  In fact, the ACA provides a 30% discount for the implementation of a comprehensive wellness program–virtually assuring that every business will “voluntarily” submit to these types of invasion of privacy. Although the university administrators claim that the data is secure and is not available to supervisors and those in the administration, it concerns me greatly that this will not be the case– (just ask those Americans who had unlawful wire taps and those that were bullied by the IRS due to their associations with certain political groups).  Big Brother is watching….from your doctors office, from your bedroom and from your back porch.   I am afraid that this particular blog may leave you with far more questions than answers….maybe we should ask Big Brother.

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International Opportunists Turning Hope into Profit: Stem Cells (and hope) for Cash or “Money for Nothing…”

Medicine is a business.  For patients with terminal illness and chronic debilitating disease, hope often trumps good sense.  Unfortunately, many savvy businessmen capitalize on those who are suffering in order to make a profit.  Genomics and stem cell research holds much promise for the future.  I believe that many once incurable diseases will be not only treated but cured through breakthroughs directly related to stem cell research.  However, much controversy surrounds the use of stem cells–ethical, legal and regulatory.  Moreover, the FDA and other agencies have well developed protocols for evaluating new therapies–most are designed to protect patients who are enrolled in clinical trials to evaluate novel therapies.

Although stem cell research and potential stem cell therapies hold great promise, new non regulated stem cell clinics are cropping up all over the world.  “Stem cell tourism” is now a booming market.  As reported in the New York Times, desperate patients travel to Mexico, Asia and Latin America in an effort to provide themselves with hope in the face of terminal illnesses.  Often, these clinic visits are cash only and require thousands of dollars for unproven therapies.  Even more disturbing is the fact that these clinics do not share or publish any results of their trials–no one really knows if there is any evidence to support the techniques or protocols that are being employed.  The clinics do inform patients that the stem cell treatments that they offer are “experimental”  and further claim that the trials are overseen by an Institutional Review Board (IRB).  However, close inspection of the IRB review and monitoring of trials shows a complete lack of oversight and no resemblance to the type of monitoring required in the US and other westernized countries.

Patients need hope.  Hope is essential for recovery.  However, trading profit for hope (without substance) is shameful.  These “for profit” stem cell therapy centers are unregulated–there is no oversight to standardize what is injected and how follow up is arranged.  If a therapy is successful, how will it be shared with the world?  Currently, most of the stem cell “cocktails” provided by these centers are top secret–I suspect if a real therapy is ever stumbled upon, it will remain proprietary.

So, where does this leave us?  Are stem cells and stem cell research a viable option?  What can we do to prevent “opportunistic” marketing of unproven therapies abroad?

Putting aside the ethical side of the stem cell research debate (that is not what this blog is about), the scientific community must continue to push the limits of our knowledge in order to provide new therapies and cure chronic disease.  Stem cells represent one possible avenue.  However, we must, as a global medical community, begin to collaborate and share findings.  When it comes to patients and human suffering we must put profit aside.  Moreover, we must attempt to regulate non US research therapy centers–allowing patients to continue to pay out of pocket for unproven therapies just doesn’t seem right.  If we are able to systematically evaluate new stem cell therapies and informed patients decide to pay out of pocket for the opportunity to be enrolled in a trial then I believe that progress can be made.  However, research and therapy formulations must be made transparent for all to share and benefit from.  Those that are selling snake oil in exchange for hope must be called out and shut down.  Patients with life threatening medical conditions deserve better.  Lets give them hope–but let’s set realistic expectations. We must provide hope for a cure.  But, we must be vigilant that others do not prey on those without hope and, in the words of Mark Knopfler and Dire Straits,  provide “money for nothing”.

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Evaluating and Implementing New Technologies: Are We Allowing PR and Marketing To Outweigh Concerns Over Patient Outcomes?

Now, more than ever, hospitals are competing.  Competing for doctors, competing for patients, competing for technology and services.  On television and radio, there are commercials that tout the experience or super-advanced technological offerings of one hospital system over other competing institutions in a given area.  Marketing and “show and tell” ads are aimed at the medical consumer in order to bring them thru the doors to seek care.  Sometimes hospital systems purchase technologies that are likely not cost effective (or even equal in efficacy to older technologies)  in order to “keep up with the Jones” across town.  Some of these expensive devices quickly end up under a layer of dust in the corner of a storeroom (after the TV commercials have been filmed of course).  More concerning, however, is that at the time some of the devices are purchased, no active staff member has been trained to use them.

As most good businessmen and women are trained to do, hospital administrators quickly begin to push for the equipment to be utilized in order to produce an acceptable return on investment (ROI).  Physicians are sent to “training courses” in order to gain experience by observing a number of cases in a center that has become adept at their use.  Although there are some limited “hands on” experiences, nothing substitutes for intensive training and proctoring in the operating room under the tutelage of an experienced surgeon (not a weekend course in Mexico).

A great example is the advent of the DaVinci surgical robot technology.  In the last several years a big selling point for hospitals in my area was the ability to showcase a “robot surgery”. With the introduction of the Da Vinci surgical system, every institution in my area began scrambling to be the first to offer the “robot”.  Physicians began to familiarize themselves with the technology and devise ways in which to utilize the device in their surgical practice.  In my institution, cardiologists and cardiac surgeons began to collaborate in order to find ways to utilize the device in the implantation of Bi-ventricular Implantable Cardioverter Defibrillators (specialized pacemakers that protect from sudden cardiac death and improve heart failure symptoms).  We found that the minimally invasive attempt to attach the special device to the left ventricle often resulted in a prolonged, ultimately open (standard) procedure in order to get the job done.  We abandoned the technique due to the fact that the previous techniques were clearly superior.  Other specialties such as urology were able to find applications such as prostate surgery that seemed to work well in the appropriate patients.  But, this is not always the case–reports have surfaced across the country involving the use of the robotic approach in less than ideal candidates.

Don’t get me wrong, innovation is never a BAD thing–however, pushing patients to have procedures with a particular piece of equipment in order to gain experience or satisfy hospital administrators certainly is.  As reported last year in the New York Times, many patients have suffered harm and had serious complications related to inexperienced operators.  Even more disturbing is that sales representatives for companies such as DaVinci have been implicated in manipulating surgeons and surgical schedules in order to gain cases and increase company revenue.  (see my blog about salesmen in the OR here)

In the New York Times this week, an article investigating the  concerns of robotic surgeries was published.  It appears that the company responsible for the DaVinci device may have been underreporting adverse events related to its use.  In medicine, the collection of data is essential to advancing the science.  When new techniques are utilized, it is critical that we are able to examine both the positive and the negative outcomes in order to learn how best to apply new techniques in order to improve the health of our patients.  There have been numerous studies of the DaVinci system and its effectiveness (and complications) conducted over the last 10 years and many have demonstrated serious flaws and generated real concerns.  In fact, as mentioned in the New York Times article, an anonymous survey of surgeons in 2010 reported a 56% rate of “irrecoverable operative function”.

In what industry or business is a 56% failure rate acceptable??? Certainly NOT in medicine when human lives are concerned.  What exactly is the FDA doing about this?  It seems that they have issued a “stern letter of warning” to physicians and hospitals concerning underreporting of complications related to robot surgeries–sounds like “double secret probation” from National Lampoon’s Animal House to me….

We must rethink how we evaluate new technologies and HOW and WHEN we adopt them.  Innovation is key–we must continue to test and evaluate new ways to treat disease in order to advance care for our patients.  But HOW we go about this process is the critical piece of the puzzle.  Rather than looking for the latest and coolest new “toy”, we must carefully examine risk and benefit of these new technologies before we completely abandon the tried and true therapies of old.  FDA regulation is likely NOT the best answer–good judgement and real concern for patient safety by physicians and healthcare systems is more likely to produce better decisions about best practices and standard of care in the future.

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Changing the Mindset in Medicine To Improve Outcomes: Prevention Rather Than Reaction

Much of my medical training in residency and fellowship was all about learning to react to particular clinical situations.  Long nights of call with exposure to a high volume of patients allowed me to quickly recognize common signs and symptoms, develop a working differential diagnosis and initiate testing and therapy right away.  This rapid fire exposure to disease was incredibly important in my development as a physician.  Moreover, the ability to react to clinical findings is essential in providing quality medical care as well as producing positive outcomes.

However, very little of my training focused on prevention.  Even today, residents and other physicians in training spend far more time treating disease rather than figuring out how to derail the disease process (even before it begins).  Certainly, we all learned about proper timing of routine screening tests for colon cancer, breast cancer, prostate cancer, etc.  In contrast, we did not spend much time learning effective ways in which we could counsel patients about lifestyle modification and risk reduction.  We did not talk much about how to educate patients about potential diseases that they may be at risk for and the potential negative impacts these diseases might have on an individual patient’s overall health status and quality of life.

Today in the Wall Street Journal, an article detailing a new report of an overall reduction in preventable cardiovascular death in the US today was published.  On first blush, this sounds like a very positive report–fewer Americans are dying of heart disease.  However, on closer examination, the data becomes quite disturbing–the largest reduction in preventable death was in the older population (greater than 75).  In the younger population (age less than 65) the decline was much less impressive.  Subgroup analysis revealed significant racial and geographic disparities as well–African Americans had a two fold higher rate in preventable cardiovascular death.  Residents of the southern states were also found to have much higher rates of preventable death.

Why is this?  What can we do to impact the large number of preventable cardiovascular deaths?

Based on this data, it seems to me that we are now seeing a large number of younger patients who are at risk for cardiovascular disease that are not being aggressively screened, evaluated and treated.  Many of these younger patients are not seeking medical attention until they experience their first (and often fatal) cardiac event.  According to the CDC nearly a quarter million of the 800K annual cardiovascular related deaths are preventable.  Long standing cardiovascular disease and its myriad of complications are expensive…in terms of dollars and in terms of human life.

The solution is all about prevention.  As cardiologists we must be more vigilant and screen young at risk populations more aggressively.  We must treat hypertension, hyperlipidemia and diabetes in younger patients.  We must spend more time counseling patients about lifestyle modification–not just smoking cessation.  Other healthcare providers in both primary care and in other specialties must also redouble their efforts on prevention.  We must all work together and refer patients who are at risk to the proper provider.  In addition, we must pay extra attention to higher risk groups such as minorities and we must focus efforts in geographies such as the south with higher than average preventable death rates.

Most importantly, we must all work to change the mindset in medicine.  Clinical competence and the ability to think on our feet and react is certainly essential and should remain a cornerstone of training.  However, we must also look a little deeper.  Obviously, we all love to be cast as the hero in the medical drama and save a life with an emergency procedure–however, it is just as heroic to prevent the emergency in the first place.  We must strive to train physicians who not only are able to react to disease and its presentations but who are also adept at recognizing risk and counseling patients to prevent negative outcomes later in life.

Ben Franklin had it right way back in the 1700s.  Even though we didn’t listen to Ben then, we have a real opportunity to listen and act now!  Remember–”an ounce of prevention is worth a pound of cure!”  Now that’s a low cost way to reduce the costs of healthcare AND save lives in the US today.

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