By MAGGIE MAHAR

Summary: Most hospital patients have no idea that the resident treating them could be coming to the end of a 30-hour shift. If he is exhausted, the resident’s judgment may be impaired. Yesterday, the union that represents some 13,000  residents and interns nationwide (CIRSEIU),  the American Medical Student Association (AMSA)  Public Citizen, the consumer advocacy organization based in Washington DC, as well as sleep scientists at the Harvard Medical School’s Division of Sleep, announced the results of survey published in BMC Medicine, revealing how little the public knows about residents’ hours.

Sleep deprivation is likely to lead to errors; residents themselves acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients.  Exhaustion also affects how they feel about their patients. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians in the U.S currently allows resident physicians to work for 30 consecutive hours up to twice per week.  The ACGME has been reviewing the IOM recommendations and is expected to announce its decision later this month.

The problem: residents represent cheap labor. Some say that the ACGME faces an inherent conflict of interest because its board is dominated by the trade associations for hospitals, doctors and medical schools that benefit from the residents’ long hours. Is this true?

Continue reading “What Most Patients Don’t Know About the Residents Who Care For Them”

By NAOMI FREUNDLICH

Last week Francis Collins, the director of the National Institutes of Health proposed important new rule changes for federally-funded investigators that are designed to increase transparency and remove many of the conflicts of interest that abound in biomedical research.

The proposed NIH rules, which are open for comment and expected to go into effect before the end of the year, represent the first time financial reporting requirements have been overhauled since 1995. The rules require investigators to disclose to their institutions all payments they receive from industry above $5,000, as well as any equity position they hold in a company. Research funding, speaking fees, paid authorship and travel expenses all must be part of this accounting. The previous limit was $10,000. The new regulations, which are aimed at reducing or removing industry bias from academic research, also require the academic medical centers to come up with a plan to manage investigator’s conflicts of interest—for example, university officials might insist that an investigator sell stock he owns in a company that helps pay for his research. Institutions will also be required to post all relevant payments (along with names of individual investigators) on a public website.

Continue reading “Shining a Light on Conflict of Interest in Biomedical Research”

By ROB LAMBERTS, MD

The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice.  What are the rules that govern my time in the office with patients?  What determines when I see people, what I order, and what I prescribe?  What constitutes “good care” in my practice?

So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient.  They are as much for my patients as they are for me, but I think thinking this out will give clarity in the process.

Rule 1:  It’s the Patient’s Visit

The visit is for the patient’s health, not the doctor’s income or ego.  This means three things:

1. All medical decisions should be made for what is in their interest, including: when they should come in, what medications they are given, what tests are ordered, and what consults are made.
2. Patients who request things that are harmful to themselves should be denied.  People who ask for addictive drugs or unnecessary tests should not get them.  Patients who are doing harmful things to themselves should be warned, but only in a way that is helpful, not judgmental.
3. All tests done on the patient should be reported to them in a way that they can understand.

Continue reading “10 Rules for Good Medicine”

By RICHARD L. REECE, MD

“- The real problem is not whether machines think, but whether men do.”  – B. F. Skinner

“If you are designing a machine, you had better think of everything, because a machine cannot think for itself.”

–  Edgeware: Insights from Complexity Science for Health Care Leaders, 1998

Obsession with medical technologies and machines characterizes American’s cultural expectations. We tend to think of our bodies as perpetual motion machines, to be preserved in perpetuity. If the face of our machines sag, we lift its faces up. If our pipes clog, we roto rooter them out or stent them. If impurities gum up our machinery, we filter them out. If our joints give out or lock up, we replace them. If we want to remove something in the machine’s interior, we take it out through a laparoscope. If the fuel or metabolic mix is wrong, we alter the mix or correct the metabolic defect with drugs If anything else goes wrong, we diagnose it and rearrange it electronically.

We are reluctant to let nature take its course. We rely on half-way technologies and machines to do the job of keeping us looking young, active, functioning , and alive. This fixation on machines and technologies is the big reason American health care is 50% more costly than that of other nations. With rapid access to machines and our reliance on them, we deliver a different product than other countries – more technologies and more machines, faster and more often. Our belief system is : Give a specialist a machine, and he or she will do the job, and we or the government will pay for it.

Continue reading “Americans and Their Medical Machines”

By DR. PULLEN

My daughter is an accountant.  She took a statistics class in high school, and another as a requirement for her major.  My son has taken a statistics course, and he is an English Literature major.  I was a chemistry major in college and have an an MD and have never taken a statistics course. I don’t even recall a lecture on statistics in medical school.  Mark Twain quoted Disraili as saying, “There are three kinds of lies: lies, damned lies and statistics.”  Reading medical journal articles reporting on the benefits and lack of benefits when reported statistically can be really challenging. Reading a report of these, or worse listening to an interested party, like a sales rep or sponsored speaker talk about a study, requires being a skeptic.  Here are some examples of how true statistics can be worse than a lie, and how what would seem to be common sense does not pay off.

Continue reading “Statistics – Using the Truth to Mislead”

By LYGEIA RICCARDI

A national survey released today by the California HealthCare Foundation shows that 66% of Americans believe we should address privacy worries, but not let them stop us from learning how technology can improve our health care. Amen.

This is particularly heartening news given that the same survey also documents for the first time real consumer benefits from the use of personal health records (PHRs). Seven percent of American now use PHRs, more than double the number in 2008. According to the survey, significant proportions of PHR users feel they know more about their health and health care, ask their doctors questions, feel connected to their doctor, and even take action to improve their health as a result of using a PHR. Continue reading “Get Privacy Right, So We Can Move On Already”

By JOHN MOORE

There have been a lot of discussions on the Net regarding the potential impact of the iPad in the healthcare sector.  At this point, there is very little agreement with some pointing to the ubiquitous nature of the iPhone in healthcare as a foreshadowing of the iPad’s future impact, while others point to the modest uptake of tablet computing platforms as a precursor for minimal impact.

Our 2 cents worth…

We believe the iPad will see the biggest impact in two areas: medical education and patient-clinician communication.

Continue reading “The iPad in Healthcare: A Game Changer?”

By MAGGIE MAHAR

Even as we set out to reform U.S. health care, we continue to train medical students as if they were going to work in the old, broken system. Today, everything about medical education needs to be re-thought, from how we select students for admission to med schools to what we teach them about how to provide safe, patient-centered care.

A shocking new report from the  Lucien Institute at the National Patient Safety Foundation reveals how today’s medical schools fail their students as it lifts the curtain on a culture of  “abuse, shame and blame”  that undermines professional morale, inhibits teamwork– and ultimately puts patient safety at risk.   (Thanks to Dr. Diane Meier for calling attention to this report on Twitter.)

“Achieving  safety in the work environment requires much more than implementing new rules and procedures,” the report observes. “It requires developing and sustaining  cultures of safety that engender trust and embrace reporting , transparency, and disciplined practices. It also requires anatmosphere of respect among the health care disciplines  and a fundamental ability of all practitioners to work together in teams.”

The white paper, entitled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care”  was prepared by an  “Expert Roundtable on Reforming Medical Education” that included a broad array of medical education leaders, students, patients, representatives from key organizations, experts from related fields, and members of the Institute. The Roundtable met in extended in-depth sessions in Boston in October 2008 and June 2009 before reaching a consensus regarding the current state of medical education—and  what medical education should ideally become.

The Roundtable participants acknowledge that med school students frequently are abused and demeaned and that this behavior is widespread. Each year, the Association of American Medical Colleges conducts a survey of medical students asking questions such as have you been “publicly belittled or humiliated?”  From 2004 to 2008, 12.7%  to 16.7%  of students answered “yes,” with “female respondents reporting higher rates” of abuse. Most often, students were humiliated by clinical faculty and residents (66% and 67%, respectively), followed by smaller but significant percentages of nurses and patients.

Continue reading “A Culture of Fear and Intimidation: Reforming Medical Education”

By BOB WACHTER

One of my interns was “running the list” with me last week (giving me a thumbnail update on the plans for each of our inpatients). It was standard stuff until he got to Ms. X, a 80ish-year-old woman admitted with urosepsis who was now ready for discharge. “I stopped her antibiotics, advanced her diet, called her daughter, and YoJo’ed her.”

Say whaa?

I’m pretty sure that the most valuable thing I’ve done in my 15 years running UCSF’s inpatient service has been to convince the hospital to hire a discharge scheduler, Yolanda Jones, a delightful woman with a big smile and the world’s most thankless job. When a patient is ready for discharge, the interns send Yolanda a note with a list of follow-up appointments, radiology studies, and other outpatient tests that need to be scheduled. She makes all the appointments, then calls the patient and intern with the info. Our hospital would cease to function if not for Yolanda; she is the unsung hero of the medical service.

And now, the process of asking Yolanda Jones to schedule discharge appointments had become a verb.

Continue reading “Verb-alizing”

By THOMAS GOETZ

In case you’ve been preserved in amber the past month, there’s been lots of excitement in  technology circles about the iPad – as well as other tablet computers – and how they’ll transform (take your pick): games and word processing and movies and magazines and newspapers and music composition.

But there hasn’t been a great deal said about their possible usefulness in healthcare.

In truth, healthcare has a horrible record with technology. Medical technology, after all, is one of the principle reasons that annual healthcare costs in the U.S. are at $2.5 trillion, and climbing. The CT scan may beguile radiologists and diagnosticians, but it’s also a horribly inefficient technology (it doesn’t scale, there’s no price transparency, etc.). In short, everything that technology is good for in the rest of the universe – lowering costs, reducing expertise – it has exactly the opposite effect in healthcare and medicine.

There have been attempts here or there to introduce consumer-style tools to medicine. Dozens of companies, for instance, offered versions of the Palm Pilot that promised to recognize a physician’s unique needs. But too often these one-off gadgets fell into the wrong quadrant of the efficiency and expense matrix. And the fact that pagers are long dead in every corner of the world except in hospitals serves as yet more proof that healthcare is a bizarro world when it comes to technology.

And consumer-facing tools have fared just as poorly. Fancy set-top boxes that promise to connect patients to their doctors via telemedicine, and cumbersome monitoring devices for people with diabetes or other chronic conditions haven’t exactly inspired confidence.

So: enter the iPad. Does it have a chance?

Yes, and for two reasons. The first is this: In the past healthcare technology has always been about the hardware – building a box that promises to do something, and then trying to educate patients or providers on how to use the box. That hasn’t worked because of bad interface design; the mission was complexity, not simplicity. But the tablets, and the iPad in particular, are designed to be as simple as possible (just one button). They’re not really about the hardware, at all – in fact, if these tools work as promised, the hardware disappears. The device will let users engage with information immediately, without having to negotiate a cumbersome interface. Indeed, the device itself vanishes and the user connects directly with the experience. That’s a powerful shift, and it has great potential for health. Continue reading “Why the iPad Matters (For Healthcare)”