Archive for June, 2014

Are Med School Graduates Prepared to Practice Medicine?

Thursday, June 26, 2014 // Uncategorized

Here is a recent article of interest from The New York Times by Dr. Pauline Chen that is important as July approaches.

Are Med School Grads Prepared to Practice Medicine?

By PAULINE W. CHEN, M.D.

April 24, 2014 11:30 am

Third-year Georgetown medical students getting ready to meet with a patient/actor.Kevin Wolf/Associated PressThird-year Georgetown medical students getting ready to meet with a patient/actor.
Doctor and Patient
Doctor and Patient

Dr. Pauline Chen on medical care.

One night early in my internship, I received a frantic page for help from a fellow intern.

Seasoned nurses had been unable to draw a patient’s blood, which senior doctors had ordered be done if his fever spiked, so they’d called the covering doctor, the first-year resident on call. For more than an hour he had poked at the patient’s arms and legs, littering the floor with blood-stained gauzes, used alcohol swabs and crumpled syringe and needle packaging. When the patient finally kicked him out of the room, howling, “I’ll hit you if you come near me again!” he called the only people he thought he could: the other interns.

“We didn’t have to draw blood in medical school,” he confessed, his eyes red behind his Harry Potter spectacles. “My med school didn’t think it was important for us to learn.”

One of us did manage to get the required blood, but for the rest of the week, we were haunted by the feeling that any one of us could easily have been in the same situation.

We had all endured four years of medical school, and we believed that all our lectures, exams and national standardized tests had made us ready to be real doctors, or at least capable interns. But the reality was that in some cases, we were unable to carry out even the most routine duties.

The intern who did get the patient’s blood on her first try had had plenty of phlebotomy experience in medical school. But she confessed she didn’t know how to prepare a patient for surgery, and had had to ask another intern to write the pre-op checklist on an index card that she could keep in her white coat pocket. The intern who wrote up the checklist came from a medical school where students prepared a lot of patients for surgery but rarely did anything in the operating room. When asked to assist on a minor procedure during her first week, she had been so awkward and unsure of herself that the scrub nurse burst out laughing.

Memories of those anxious first months of internship rushed back recently when I read about a new effort to improve the transition between medical school and residency training in the journal Academic Medicine.

Each July at teaching hospitals across the country the most seasoned residents leave to begin independent practice, younger residents behind them move up a rank, and freshly minted M.D.s take their place as interns at the bottom of the ladder.

The transition can be perilous: patient outcomes can suffer, and young doctors can be particularly vulnerable to burnout. Observers have long attributed the notorious “July effect” to the rookies who have stepped up to the plate, but in the wake of major reforms in the way doctors and residency programs are accredited, medical educators have begun believing that there’s another reason.

Beginning in 1999, accrediting organizations began to study how they might better assess the competency of young physicians. Too much weight, they thought, was placed on counting the time spent in training and not enough on gauging measurable skills.

To remedy this weakness, they introduced a set of defined “competencies” to judge the preparedness of young doctors. In the process, however, they discovered another serious flaw in the system. Instead of working as parts of a seamless and well-conceived whole, medical schools and residencies were operating independently of one another, teaching and emphasizing aspects of medicine that weren’t always relevant to the next step of a young doctor’s career.

One of the most glaring examples of this was the transition between medical school and internship. Although, for example, most medical schools required that senior medical students complete a “sub-internship,” a month in the hospital as an acting intern, few structured this requirement around common goals, guidelines or input from the directors of residency programs. Moreover, depending on the hospital, the team of senior doctors and the medical school’s particular educational philosophy, the sub-internship experience could vary widely, with some students toiling away as full-on intern replacements and others languishing on the sidelines as extraneous observers.

Educators in some of the smaller specialties, like surgery, family medicine and obstetrics and gynecology, responded first, holding conferences and conducting specialty-wide surveys to create explicit goals for students preparing for their internships. Late last year, a panel of experts put together by the Association of American Medical Colleges came up with a set of general skills that medical students needed to have before starting a residency, skills like conducting a physical exam, recognizing clinical emergencies and obtaining informed consent for procedures.

Now educators in the largest specialty, internal medicine, which attracts as many as a third of all medical students, have begun a similar effort, the article in Academic Medicine explains. They distributed a questionnaire to their colleagues at residency training programs, asking them what skills were necessary for students starting internships, and nearly 300 program directors responded. And while their answers were not entirely surprising, the degree to which they agreed was.

The overwhelming majority believed that interns should show up on their first day of work knowing when to ask for help, how to communicate well with nurses and how to manage their time. Only 5 percent believed that new interns needed to have more medical knowledge or procedural experience before starting work.

“With so much agreement, you might wonder why it has taken us so long to coordinate our education and training,” said Dr. Steven V. Angus, the lead author and program director of the internal medicine residency program at the University of Connecticut School of Medicine in Farmington. “But we educators had this silo mentality and were thinking, ‘I know what my job is, and someone else can deal with what happens to the students before or after.’”

During the last attempt to create sub-internship guidelines for internal medicine in 2002, for example, fewer than a quarter of residency program directors responded to the survey. Guidelines emerged but the reaction was tepid; like customers at an all-you-can-eat buffet, the majority of those in charge of the medical school sub-internships picked only those recommendations they deemed interesting.

But Dr. Angus and his co-authors are optimistic about this latest effort. For one, it appears to be the largest collaboration ever taken between internal medicine educators in medical schools and residencies. And with three-quarters of the program directors responding to the questionnaire, it also represents the most enthusiastic one, a sign that old attitudes are changing.

“We’re stepping out of our silos and talking a lot more now,” Dr. Angus said. “And most of us are embracing the change because we know it will be better for our students and for the patients they care for.”

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World Cup Travel Advice

Thursday, June 12, 2014 // Uncategorized

Large groups of people from all over the world congregating together is a perfect storm for infections diseases as indicated on this release from Pro Med Digest.

MEASLES UPDATE (23): TRAVEL ADVICE, WORLD CUP, PAHO/WHO
*******************************************************
A ProMED-mail post
< http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
< http://www.isid.org>

Date: Fri 6 Jun 2014
Source: Pan American Health Organization (PAHO)/World Health
Organization (WHO) [edited]
< http://www.paho.org/hq/index.php?option=com_content&view=article&id=9679&Itemid=1926>

The Pan American Health Organization/World Health Organization
(PAHO/WHO) is reminding people who plan to attend the 2014 FIFA World
Cup, which starts on 13 Jun 2014 in Brazil, to make sure they are
protected against vaccine-preventable diseases, especially measles and
rubella.

Intensified international travel and population movement associated
with mass events such as the World Cup increase the risk of imported
cases of measles, rubella, and other vaccine-preventable diseases. For
this reason, PAHO/WHO is calling on travelers to make sure they are up
to date on their vaccines and, if not, to get vaccinated against
measles and rubella, ideally at least two weeks before traveling.

In the Americas, endemic transmission of measles was interrupted in
2002 and transmission of rubella in 2009. However, measles continues
to circulate in other parts of the world, and some countries in the
Americas have reported imported cases. PAHO/WHO’s recommendation seeks
to protect the achievements of the Americas in eliminating
vaccine-preventable diseases.

This year’s FIFA World Cup is expected to attract some 600 000
visitors from around the world. Of the 32 countries with teams
participating in the games, 19 reported measles cases in 2013.

During the 12th annual Vaccination Week in the Americas, held [26 Apr
to 3 May 2014], PAHO/WHO issued a call to action for people to protect
themselves against measles, rubella, and other vaccine-preventable
diseases in view of the approaching World Cup. “These viruses continue
to circulate in other regions of the world. The risk of reintroduction
of these diseases is especially high during mass-attendance events
such as the 2014 World Cup,” said PAHO director Carissa F Etienne
during Vaccination Week in the Americas. “Getting vaccinated against
measles and rubella is your best shot to protect yourself, your
family, and all the people of the Americas.”

PAHO/WHO recommends that travelers check to make sure they are up to
date on all their vaccines. Anyone over 6 months old who has not been
vaccinated, or who does not remember if they were vaccinated, should
get vaccinated against measles and rubella at least 2 weeks before
traveling.

“PAHO and WHO routinely recommend that persons traveling to warmer
climates should also use sun screens, insect repellents, and
protective clothing to prevent sun damage and vector-borne diseases
like dengue and malaria,” said Dr Jon Andrus, PAHO’s deputy director.


communicated by:
ProMED-mail
< [email protected]>

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Good Doctors/Bad Ratings

Wednesday, June 11, 2014 // Uncategorized

Online ratings for doctors are ubiquitous and have little relationship to the quality of care that they deliver.  From the Daily Beast.

You Can’t Yelp Your Doctor

Some of the country’s best doctors have the worst patient satisfaction scores. Here’s why.
Part of being a doctor is learning to suppress your feelings. You get good at being what people need you to be. But it slowly transforms you into something you couldn’t have foreseen—a sort of Stepford doctor—pleasing everyone with your perfect smile and agreeable demeanor, hoping that your patient satisfaction survey will be favorable, no matter the cost.

Press Ganey is one of the top providers of patient satisfaction surveys, according to the Forbes article, Why Rating Your Doctor Is Bad For Your Health.

The government has bet big on these surveys, as a recent article in Forbesnotes. Armed with the idea that “patient is always right,” Washington figured that more customer satisfaction data “will improve quality of care and reduce costs.”

That turns out to have been a bad bet.

In fact, the most satisfied patients are 12 percent more likely to be hospitalized and 26 percent more likely to die, according to researchers at UC Davis. “Overtreatment is a silent killer,” wrote Dr. William Sonnenberg in his recent Medscape article, Patient Satisfaction is Overrated. “We can over-treat and over-prescribe. The patients will be happy, give us good ratings, yet be worse off.”

It’s Economics 101. If we ask drug-addicted patients to grade their physicians on how satisfied they are with the “service,” then a high score will likely indicate they got the opposite of good medical care. It doesn’t take a genius to figure out how putting addicts in charge of the patient encounter contributes to the $24 billion in excess medical costs caused by prescription opiate abuse. Nevertheless, some emergency rooms are even offering Vicodin “goody bags” to improve their ratings.

Thanks to patient satisfaction scoring, unnecessary antibiotic prescriptions are also on the rise, adding to the deadly menace of drug-resistant bacteria. A patient demanding unnecessary antibiotics is one of the things that doctors hate most, yet nearly half of physicians surveyed said they’ve had to “improperly [prescribe] antibiotics and narcotic pain medication in direct response to patient satisfaction surveys,” as reported in Forbes.

We find ourselves in another kind of world—one turned upside-down—where the most ethical doctors are ousted and the most servile are raised high.

“The mandate is simple,” wrote Dr. Sonnenberg. “Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.” So instead of better care and cheaper care, satisfaction scoring is making patients sicker and driving up costs. Indeed, the UC Davis researchers found the most satisfied patients account for 9 percent more in total health-care costs—and that does not include the excess monies wasted on trying to please the rest.

But when physicians don’t acquiesce, they pay a price. Last year, The Atlantic profiled a physician who quit due to the pressure to prescribe narcotics. In many cases, doctors can’t keep their jobs or make partner if their scores aren’t—not just good—but stellar. And many physicians claim that hospital administrators explicitly tell them to do whatever it takes to raise scores even if it means compromising their professional standards.

So why is this happening?  As one fed-up physician blogger explained in a story he entitled The Focus on Patient Satisfaction is Enough to Make you Sickit’s for “the same reason the IRS collects taxes and not seashells: Money.”

And it’s big money. The companies doing the studies—and their investors—are getting rich. According to Forbe, Press Ganey, the biggest of the survey firms, went from a valuation of $100 million to nearly $700 million in just four years—bringing in over $200 million a year. And with cash comes political influence, so of course the government plays along. Medicare uses the surveys to withhold payment to doctors and hospitals that don’t have high scores.

As Forbes points out, by 2017, Obamacare’s “pay for performance” program mandates that hospitals will lose 2 percent of their Medicare payments if they perform poorly on quality measures—some 30 percent of which will be based on patient satisfaction scores. Hospitals are investing in capital upgrades like escalators to improve the “customer” experience.  Meanwhile, doctors are under even more pressure to “please the customers”—even if it means unnecessarily scoping them, irradiating them, or plying them with toxic and addictive pills.

To be sure, physicians know that good feedback is important, but these scores aren’t even good feedback.  “We are not given access to [the reasons] why they were dissatisfied. We can never learn from our mistakes,” one emergency department doctor was quoted in Medscape.

While patients who read this may be unmoved by the doctors’ plight, understand that not all doctors are taking this lying down. In order to protect themselves, doctors are filling patients’ charts with diagnoses like “drug addiction” and “mental illness”—not exactly the kind of thing you want in your permanent medical record.

The public should be outraged that they’re being used like this and flattered into believing these scores ensure good care—while putting their lives in jeopardy. They should be outraged that hospitals and health systems are so corrupt that they play along instead of demanding that scores create better outcomes, not just better profits. These scores should be aligning the interests of patients and physicians—because in a perfect world, physicians’ and patients’ interests are exactly the same.

Instead we find ourselves in another kind of world—one turned upside-down—where the most ethical doctors are ousted and the most servile are raised high. In this world, doctors are forced to violate their sacred oaths to keep their jobs. In this world, once-proud physicians are over-prescribing and over-ordering, grinning and pretending, stepping and fetching.

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Patients Should Read Their Records

Tuesday, June 10, 2014 // Uncategorized

There is a push to give patients access to their medical records.  Frequently, when I share with patients copies of consultations from other physicians, they point out inaccurate information.  This is from yesterday’s  Wall Street Journal.

 

Health-Care Providers Want Patients to Read Medical Records, Spot Errors

The aim is to move patients and doctors into a relationship of “shared accountability”

By

Laura Landro

 

June 9, 2014 7:02 p.m. ET
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More health care providers are encouraging patients to correct errors in their medical records, allowing them to view their doctors’ notes about them online, and add their own thoughts. WSJ’s Laura Landro discusses with Tanya Rivero on Lunch Break. Photo: Getty

Health-care providers are giving patients more access to their medical records so they can help spot and correct errors and omissions.

Studies show errors can occur on as many as 95% of the medication lists found in patient medical records.

Errors include outdated data and omissions that many patients could readily identify, including prescription drugs that are no longer taken and incorrect data about frequency or dosage.

Patients also are being asked to fill in the blanks about pain relievers and other over-the-counter medications, as well as supplements and vitamins, all of which can interact with prescription drugs.

Mary Ellen Sexton, left, found outdated data in her husband Lynn’s, center, medical record. Patients’ checking ‘only helps me,’ says their physician, Richard Martin, right. Wendy Wilson/Geisinger

Technology is giving the efforts a boost: More than half of doctors use electronic medical records, compared with just 17% in 2008, according to the federal government, which offers financial incentives to providers tied in part to giving patients access to their health information online.

Several large medical providers, including Cleveland Clinic, Mayo Clinic, the Veterans Health Administration, Geisinger Health System and Kaiser Permanente, are giving patients direct online access to their doctors’ notes. And they are experimenting with different ways to solicit feedback and allow patients to correct or add to their records.

“If we don’t have accurate data we can’t take care of patients appropriately,” says Jonathan Darer, chief innovation officer at Geisinger. The aim is to move patients and doctors into a relationship of “shared accountability” and more effective medical care, he says.

While studies have shown that immediate harm to a patient because of faulty medical records is rare, such errors can lead doctors to miss important information, such as whether patients aren’t taking their drugs as prescribed, which can lead to worsening of a disease or condition. In an emergency, it’s critical to know what drugs are in a patient’s system, as hospital staff may prescribe new drugs that conflict with them.

Common Errors in Medical Records

Outpatient medical records often contain missing or inaccurate data, including:

  • New prescription medicines aren’t listed, or medicines are listed that the patient isn’t taking anymore.
  • An incorrect or outdated dosage of a prescription medicine.
  • Duplicate prescriptions for brand-name and generic medications.
  • Over-the-counter remedies, such as pain relievers, vitamins or other supplements, aren’t listed.
  • Incomplete or missing information about medication allergies.
  • Erroneous information about treatment outcome, such as a condition that is noted as resolved but is still a problem.
  • Updated information about lab results is missing.
  • Details about symptoms, as reported by the patient, are missing.
  • Inaccuracies in diagnosis.
  • Missing information or updates from another provider.

Source: Geisinger Health System; NORC/University of Chicago

Even when gaps in the medical record are a result of the patient’s failure to provide updated or complete information, providers might still face legal liability in the event of an adverse or allergic reaction or a prescription that doubles something the patient is already taking. The risk is especially high for older patients, who often take several medications for one or more chronic diseases and may not recognize that, say, a brand-name drug and a generic-name drug are the same.

Patients with access to their own medical information are more likely to ask questions, identify inaccuracies and give additional information that might affect data in their records, according to research conducted by research organization NORC at the University of Chicago, under contract with the federal Office of the National Coordinator for Health Information Technology.

In a pilot study that the Chicago researchers conducted with Danville, Pa.-based Geisinger, patients with chronic diseases like diabetes and heart failure were invited to go online between November 2011 and June 2012 to update the medications in their electronic health records before a doctor’s visit. They had the option to indicate which meds they were no longer taking, which they were taking differently than described and which they were taking that weren’t listed. Geisinger pharmacists followed up with the patients to update their records and notify doctors and case managers about changes.

In nearly 90% of cases, patients requested changes to their medication records, including changes to doses and frequency of existing medications and requests to have new medications entered.

On average, patients had 10.7 medications listed, with 2.4 requested changes.

Information reported by pharmacists suggests that in 80% of cases, patient feedback was accepted and resulted in changes to the record. For patients who couldn’t be reached by phone to confirm, updates were limited to discontinuing an old medication, adding a new OTC drug or correcting a clerical error such as a duplicate prescription.

Focus group participants said access to the medication list better prepared them for doctor visits and enabled them to take a proactive role in managing their care.

A few stopped taking medications that could have been detrimental to their health, such as a patient who had surgery and reported that he had begun taking B-12 vitamins. He got a call from a Geisinger staffer telling him to stop taking the vitamins to prevent overdose, because he was already receiving B-12 injections.

In the short term, Geisinger’s Dr. Darer says, “there may be some awkward questions from patients about data discrepancies or inaccuracies.” But in the long run, he believes malpractice liability will be reduced.

“The data will be better, and patients will have been part of the process,” Dr. Darer says.

Geisinger is currently adopting the medication feedback initiative more broadly in the health system, which serves northeastern and central Pennsylvania. It also is expanding its use of another initiative, Open Notes, which currently allows some 168,000 patients to view their doctors’ notes online through a secure patient portal.

Patients can add their own notes, and starting this summer family caregivers will be able to add notes, including asking for corrections about patients who may not be able to comment on their own.

Barbara Pierson, age 70, who manages an insurance office near her home in Howard, Pa., says her electronic record on the Geisinger health portal showed she was taking both a brand-name prescription drug and a generic version. She had asked her doctor to switch her to the generic because of the lower cost, but after the change the brand-name drug continued to appear in the record.

“I just happened to go online and check before my last appointment, so I was able to tell them about it when I went in,” she says.

Mary Ellen Sexton, 78, used the Geisinger portal to check her own health records and those of her husband Lynn, 81, a retired machinist who has had a heart attack, bypass surgery, two angioplasties, a stent, hip and knee surgery and gallbladder surgery.

“With Lynn at the stage he’s at with medications, I check it quite often,” Mrs. Sexton says.

After every visit with their physician, Richard Martin, Mrs. Sexton checks OpenNotes to review what was said during and after the appointment.

Mrs. Sexton recently noticed that her husband’s record still listed a cough medicine that his doctor had recommended for a bad cold earlier this year, along with a prescription drug delivered by an inhaler to help with breathing trouble.

She also noticed results were in for a blood test of his thyroid, which was listed as abnormal.

Her active approach “only helps me,” Dr. Martin says. She informed him about the change to the medication list. And while he usually reviews labs at the end of the day, Mrs. Sexton beat him to her husband’s report.

“She was Johnny on the spot,” bringing the abnormal labs to his attention so he could call in a medication right away.

At first, Dr. Martin says, he expected younger patients to be the most active in checking the doctor’s notes and records.

“But it really turned out older folks use it the most and get the most benefit, because they are the sickest and taking the most medications,” Dr. Martin says.

Write to Laura Landro at [email protected]

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