By James Salwitz, MD

Terry is a particularly difficult patient.  She is not hard because of her cancer, which is in remission, nor is there a problem with pain, of which she has little, and Terry is not particularly demanding for the nursing staff.  No the real problem, the challenge, the thing that makes her so difficult is that Terry is married. Terry is married to Dr. P and he is a particularly difficult man.

Terry’s husband loves Terry very much.  He wants her to have the very best care.  Dr. P makes certain that all the doctors know everything that is going on, all the time; he makes sure the nurses are on top of every detail; he demands the best from the all the hospital staff.  In fact, Dr. P works so hard to control Terry’s care, to stay on top of her case, to monitor every moment, it is nearly impossible to take care of Terry.

There are many challenges for doctors taking care of other doctors or their families, or, in reverse, there are many challenges for doctors when they seek care for themselves and their families.  The result of this conflict is often inferior medical care.  Therefore, wanting to honor and help doctors get good quality treatment let us take a moment to review the doctor verses doctor verses medical system dilemma.

First, it is hard for doctors to decide where to go for medical care.  If you stay in the same community where you practice you lose some privacy and perhaps even respect in the physician community.  Who do you chose and how do you avoid offending the other physicians you do not use?  If you leave your own area, you lose the convenience and familiarity of getting care close to home.

Continue reading “The Doctor as Patient”

By David Glenn

Nearly two million Americans work as home health aides and personal care aides — a number that is projected to climb above three million by 2020.

This is low-paid, low-status, exhausting work. A typical shift might include helping a client bathe, preparing her meals, changing her linens, helping her walk safely to the store, sweeping her floors, and helping administer medications (even though in many cases these aides aren’t licensed to do so). There is also a complex burden of emotional labor: comforting, cajoling, making small talk.

Most home aides are hired and paid by third-party agencies, which are often hugely profitable, in part because domestic workers have lacked minimum-wage and overtime protections under the so-called “companionship exemption” to the Fair Labor Standards Act.

After years of organizing by the National Domestic Workers Alliance, the Paraprofessional Healthcare Institute, and other groups, the Obama administration issued a preliminary regulation late last year that might finally bring an end to that exemption.

Continue reading “The Wages of Home Care”

By Will Saunders

Although healthcare providers are making progress in adopting health IT, Americans seem to be resistant to change to Electronic Health Records (EHRs). In fact, only 26 percent of Americans want their medical records to be digital, according to findings from the third annual EHR online survey of 2,147 U.S. adults, conducted for Xerox by Harris Interactive in May 2012.

Last month the Institute of Medicine issued a seminal report entitled “Best Care at Lower Cost: The Path to Continuously Learning Health in America.” The report estimates the American healthcare system suffered a $750 billion loss in 2009 from inefficient services and administrative expenditures. The report is grounded on the principle that effective, real-time insights for providers and patients which result in collaborative and efficient care depend on the adoption and use of digital records.

As people are naturally resistant to change, education will be key in gaining support among Americans for the transition to EHRs. If providers can help patients understand “what’s in it for me,” that will likely go a long way in making Americans feel more comfortable with the switch to digital.

Let’s take a look at five ways EHRs directly impact the patient. For these examples, we’ll use a fictitious patient named “Joe”:

• Health Information Exchanges (HIE): HIEs work on the principle of a network – they grow stronger as more participants join. If Joe’s primary care doctor switches to digital, that’s a great step in the right direction. However, it isn’t truly meaningful until his primary care doctor joins an HIE and begins sharing Joe’s patient health history, medication history, lab results, family and social history and vital statistics with his specialists, emergency care providers, and so on. This sharing of information helps ensure that Joe gets the best quality of care, because all of his providers will be in sync and have the most up-to-date information. It also helps reduce the amount of duplicate exams and labs Joe will be asked to give.

Continue reading “Five Reasons Americans Should Want Electronic Health Records”

By Frank Spinelli

Both participants and caregivers in long-term care programs face a myriad of difficulties. Participants with long-term services and supports needs often have many health issues, meaning they are in constant transition between care environments and providers with their needs ever-evolving. As a result of visits to a number of doctors on a regular basis and the number of providers who support them, the participant’s information lives in multiple locations. This can lead to discrepancies between providers and the participant having to constantly provide the same information.

Caregivers, especially family members, are also facing great challenges. It’s a full-time job to care for someone in the home – it takes nearly 40 hours a week – and searching for a trusted service provider to take over can be another job in and of itself.

The root of the problem is that many long-term care programs are focused on the providers and not necessarily the people – those receiving the services and those providing them. Often, no one has the full picture of the participant’s health, which can lead to suboptimal care. An ideal situation is for everyone involved with the participant to be up-to-date and have a full-picture of their health and well-being at all times. When they are, services can be administered effectively with less risk for everyone involved.

Continue reading “Refocusing Long-Term Care on People: The Three I’s  ”

By James Salwitz, MD

Today would have been easier if I did not give a damn.  Easier if patients were clients.  Easier if medical advice was causal suggestion.  Easier if I believed that patients were solely responsible for their health.  Easier if suffering was not real.  Much easier, if I did not care.

However, despite the popular movement from “the doctor knows best” towards shared decision-making, I feel responsible for my patients.  What happens to them is very important to me.  I mean this not as an objective definition of a doctors  “job.”  I am talking about the personal love of a caregiver for his community.  Therefore, while I respect the freedom of each patient to control their own future, sometimes when they exercise that right it hurts.

First, there was my patient who received multi-agent complex chemotherapy and then vanished for three weeks.  Despite severe mouth sores, fevers, rapid weight loss, numbness of his feet and daily vomiting, he did not call.  He had attended chemo class, had received written instructions, and had at least six emergency phone numbers (and my email). Nonetheless, he did not reach out. On one occasion, one of my staff even spoke to him by phone and he did not mention the disaster.  He just suffered and deteriorated.  Now, I need to stop his treatment and can only try to salvage what remains of his frail health.

Continue reading “Your Doctor Cares (No, Really)”

By Danielle Ofri

I can’t tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren’t sure of the difference between the two, then “God’s Hotel” is the book for you. It’s an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco’s Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, “slow medicine,” as Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Continue reading “Slow Medicine”