Everybody hates curbside consults – the informal, “Hey, Joe, how would you treat asymptomatic pyuria in my 80-year-old nursing home patient?”-type questions that dominate those Doctor’s Lounge conversations that aren’t about sports, Wall Street, or ObamaCare. Consultants hate being asked clinical questions out of context; they know that they may give incorrect advice if the underlying facts and assumptions aren’t right (the old garbage in, garbage out phenomenon). They also don’t enjoy giving away their time and intellectual capital for free. Risk managers hate curbside consults because they sometimes figure into the pathogenesis of a lawsuit, such as when a hospitalist or ER doctor acts after receiving (non-documented) curbside guidance and things go sideways.
There is some evidence to support this antipathy. A recent study published in the Journal of Hospital Medicine examined 47 curbside consultations by hospitalists, in which formal consults by different hospitalists (unaware of the details of the curbside encounter) were performed soon thereafter. Conducted by a team of researchers from the University of Colorado, the study found that the information given to the curbside consultant was incomplete or inaccurate roughly half the time, and that management advice offered via the two forms of consultation differed 60 percent of the time. (In those cases in which the consultant was given inaccurate or incomplete information, the advice differed more than 90 percent of the time!) This is not the first warning about the dangers of such consults (see also here and here), and it won’t be the last.
I have two sons, both healthy happy boys, both brought into this world in very different ways. I work in healthcare and like many readers of THCB, the business of healthcare is often viewed through the business lens. When we become the healthcare consumer, and are knee deep in the conundrum that is our healthcare system, the perspective changes dramatically.
Ezra was born in a major medical center, under the supervison of state of the art OB/GYNs, with all of the greatest technology, and under the care of the best nurses. My wife wanted a “natural birth”, so natural that I affectionately describe it as a “granola birth”. We were active duty military at the time so our choices were limited. She hired a birth doula, read Ina May’s “Guide to Childbirth”, chose to see a Women’s Health Nurse Practitioner for her wellness visits, and was adamant that she did not want an epidural.
As we approached 40 weeks the adventure began. At 36 weeks she could no longer see the NP, she had to now see the OB/GYN. The OB/GYN began to make reference to not allowing us to go past 40 weeks, it would “endanger the child”. My wife began to feel very uncomfortable and that she was slowly losing control of the experience she wanted to have. At the 40 week visit, the OB/GYN gave a very stern warning that an “induction was now necessary for the safety of the baby” regardless of there being no indication that Ezra’s wellbeing was compromised. We resisted as much as possible (with the help of no beds in the maternity ward) but at 41 weeks and 2 days, doctors’ orders brought us into the hospital for an induction.
There’s a high-profile and important paper in JAMA this week by Sunil Eappen and colleagues. The study looked at surgical discharges during 2010 from a single 12-hospital system and came to the conclusion that admissions that include a surgical complication were associated with a higher profit (defined as the contribution margin) than admissions without complications. The authors conclude that this creates a disincentive for hospitals preventing surgical complications since they might see reduced profits as a result. This is a very provocative finding and it’s getting a lot of well-placed media attention, as you might expect. There is an important caveat with the study that I would like to highlight.
In the study, the authors report that admissions with surgical complications result in $39,000 higher “profits” if the care is reimbursed via a private payer and $1800 if Medicare is the payer. However, as Dr. Reinhardt correctly noted in the editorial,
“Allocating profit and loss is exquisitely sensitive to the many assumptions made in economic modeling and must be performed carefully to provide useful evidence about the financial ramifications of surgical complications and other services.“
His concern dealt mostly with how the authors allocated fixed costs in their calculations. My concern has to do with what the authors assumed happens to an empty bed once a patient is discharged in a US hospital.
An important study in the Journal of the American Medical Association finds that misdiagnosis is more common than you might think. According to the study, almost 40% of patients who unexpectedly returned after an initial primary care visit had been misdiagnosed. Almost 80% of the misdiagnoses were tied to problems in doctor-patient communication, and more than half of those problems had to do with things that were missed in the patient’s medical history.
The results of this study shouldn’t be surprising if you’re a regular reader here – they are another example of a system that isn’t working as well as it could for patients, and doctors. Doctors – and the medical professionals who help them in their work – are the best educated and best trained than they have ever been. They have more access to medical information and technology than at any time in our history. And yet, U.S. government data show that the typical doctor visit involves 15 minutes or less with your doctor. Medical records are kept in fragmented, uncoordinated ways.
In the past, neither hospitals nor practicing physicians were accustomed to being measured and judged. Aside from periodic inspections by the Joint Commission (for which they had years of notice and on which failures were rare), hospitals did not publicly report their quality data, and payment was based on volume, not performance.
Physicians endured an orgy of judgment during their formative years – in high school, college, medical school, and in residency and fellowship. But then it stopped, or at least it used to. At the tender age of 29 and having passed “the boards,” I remember the feeling of relief knowing that my professional work would never again be subject to the judgment of others.
In the past few years, all of that has changed, as society has found our healthcare “product” wanting and determined that the best way to spark improvement is to measure us, to report the measures publicly, and to pay differentially based on these measures. The strategy is sound, even if the measures are often not.
This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.
An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.
A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.
Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.
“The more you learn, the more you realize you don’t know.”
You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.
The implication of this for the practice of medicine is that a little knowledge can be very dangerous.
What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.
I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)
The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it, it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.
Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing.
Although misdiagnosis may kill up to 80,000 annually—more people each year than firearms and motor vehicle accidents combined—you won’t find it on the list of the country’s leading causes of death.
Most Americans don’t realize how frequently well-meaning medical providers get it wrong. Just last year Johns Hopkins researchers found that one in 12 ICU patients die from something other than what they were being treated for. Aside from a handful of instances covered by the national media, misdiagnosis hasn’t received much attention from the public or the medical community. One such tragedy is the death of Rory Staunton, a 12-year-old boy who was treated for an upset stomach and dehydration instead of sepsis, a severe response to infection that requires immediate treatment with antibiotics. To make a complex diagnosis like sepsis, a doctor may need to assess a couple dozen different factors.
One solution is to arm clinicians with better problem-solving tools and improved IT systems to help them identify possible diagnoses faster and more accurately, especially for conditions that are commonly confused or missed altogether. This week at Johns Hopkins, a team of researchers shared some promising results about a new way for emergency medicine doctors to accurately detect stroke in patients with dizziness.
In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in – well, actually, poured in not that much money at all when you think about it – lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.
Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.
The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.
It is as natural for doctors, hospitals, health plans and others to aggressively affirm their “patient-centeredness” as it is for politicians to loudly proclaim their fealty to the hard-working American middle class. Like the politicians, the health care professionals no doubt believe every word they say.
The most accurate measure of “patient-centered” care, however, lies not in intentions but implementation. Ask one simple question – what effect does this policy have on patients’ ability to control their own lives? – and you start to separate the revolutionary from the repackaged. “A reform is a correction of abuses,” the 19th-century British Parliament member Edward Bulwer-Lytton noted. “A revolution is a transfer of power.”
With that in mind, which purportedly patient-centric policy proposals portend a true power shift, and which are flying a false flag?
Falling Short Of Shifting Power
The two most prominent examples of initiatives whose names suggest power sharing but whose reality is quite different are so-called “consumer-driven health plans” (CDHP) and the “patient-centered medical home” (PCMH). Both may be worthy policies on their merits, but their names are public relations spin designed to put a more attractive public face on “defined contribution health insurance” and “increased primary-care reimbursement.