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Tag: Quality

Rethinking compassion in medicine

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By Michael Miller

Two recent events made me think about how traditional medical care and medical education address the issue of compassion.

The first was at the annual dinner for the Kenneth B. Schwartz Center when they gave out their annual Compassionate Caregiver Award, and reviewed the accomplishments of  previous awardees.  These individuals have all made remarkable differences in the lives of patients and families through their empathy and personal connections.

The second event was reading about the passing of Florence Wald, the former Dean of Nursing at Yale who organized the first hospice in the United States in 1974 because of her interest in compassionate care at the end of life.

While there has been much discussion about:

  • Shortages of primary care clinicians
  • How medical school graduates are increasingly going into specialties
  • Medical schools are thinking of replacing the requirement that applicants have taken organic chemistry with requirements for more biochemistry or genetics
  • A survey of physicians finding that over the next three years 49% plan to reduce the number of patients they see or stop practicing entirely, and 60% would not recommend medicine as a career

All these relate to the structure and content of physician education and training.  And I have two proposals:

First, while  medical school education has progressively shifted from teaching in hospitals to more out-patient and community care, I think doing more to show medical students and residents the rewards of community primary care would be a good step for increasing the number and prestige of primary care clinicians.

And second, while medical schools require students to go through rotations in pediatrics, Ob/Gyn, medicine, surgery and psychiatry, I don’t know of any that require students to go through a hospice rotation.  This may be because medicine and society try to discount death as a failure, but a hospice rotation would be a great opportunity for teaching students about empathy and compassion, and shifting the discussion of death within the context of medical education so that it is viewed more as part of the continuum of life.  In addition, having medical students in a rotation where they are not reporting to (and trying to impress) senior physicians, but rather working with nurses and social workers, also might provide them with a better perspective on teamwork in healthcare delivery – as well as a dose of humility.

The value of hospice (or palliative care) rotations for students does seem to be growing.  An article from 2006 reported that the University of Arizona was thinking about requiring a hospice rotation.  And the American Association of Medical College’s web-site has an article from 2004 about how Mt. Sinai has integrated palliative care into their curriculum.

Does anyone know of any medical schools that require hospice rotations for medical students or have integrated these types of programs into their core curriculum?  (BTW – A major focus for the Schwartz Center is grand rounds and other educational programs about compassionate care and patient-caregiver communications for both established clinicians and students.)

And lastly, it should also be recognized that expanding young physicians communications and empathy skills should help them work better with their patients, (and patients’ families), which could help reduce unnecessary and costly care.

Dr. Michael Miller started HealthPolCom Consulting in 2000 after 12 years in health policy positions in Washington, DC.  He works with an extensive network of policy and communications consultants. He blogs regularly at Health Policy & Communications, where this post first appeared.

Electronic health records provide the foundation for clinical excellence

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By Scott ShreeveScottshreeve

I have mentioned this many times but it bears repeating with three
recent news articles – the electronic health record itself is not a
game changer but it is a powerful information gathering tool.

However,
by gathering information in a single collaborative place, EHR
technology allows all clinical providers to measure, monitor, and begin
to improve the way they provide care. It is this later part, which is part of the overall organizational transformation enabled by the technology (not solely because of it), that allows an organization to achieve the promised high performance results of an often painful EHR implementation.

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America’s CEOs set priorities for Obama Administration

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By Brian Klepper

Bksobersmile
This past Monday and Tuesday, The Wall Street Journal convened an extraordinary conference of about 100 CEOs to develop and recommend issue priorities for the new Administration. (See the participant list here.)

This meeting brought together the nation’s industry power players. Several Senators and Congressional representatives participated, as well as Rahm Emanuel, the President-elect’s new Chief of Staff, and others who advise Mr. Obama.

Based on their business’ core focus, the attendees were assigned into four major areas: 1) Finance and the US Economy, 2) Energy and the Environment, 3) American and the Global Economy, and 4) Health Care.

Then in the General Session that followed, the focus groups’ recommendations were incorporated into a final list and reranked by all the participants. Here’s the graph showing the relative ranking of all issues.

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CAP’s Blueprint for reform

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By Joshua SeidmanSiedman

The Center for American Progress (CAP) released a new “Blueprint for Reform” that focuses on how to fix the delivery system. This well-constructed
document and provocative forum was spearheaded by CAP CEO John Podesta (former Clinton White House Chief of Staff) and Jeanne Lambrew.

There are a few things that really show good progress in the
national debate. First, the fact that CAP has chosen this critical time
at the precipice of the national health care reform debate to focus
attention on reforming care as well as coverage will be helpful to
facilitating that discussion in 2009 policy debates (they, of course,
support coverage initiatives as well but those aren’t addressed in this
document).

Second, the quality and thougtfulness of the work and recommendations is high. Not surprising given the exceptional collection of authors with each chapter co-authored by a physician and a policy expert. These
include: Don Berwick, Tom Lee, Judy Hibbard, David Blumenthal, Bob
Berenson, Paul Ginsberg, Steve Schroeder, Dora Hughes, Chiquita
Brooks-LaSure, Karen Davenport, and Katherine Hayes.

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Baseball and Health Care: Only One Is a Spectator Sport

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By Joshua SeidmanSiedman

It’s fascinating when two of my passions collide in the opinion pages of the New York Times like they did over the last week. On Friday, October 24, some seriously strange bedfellows came together to write about, “How to Take American Health Care from Worst to First.” Strange enough that Newt Gingrich and John Kerry joined together, but
the lead author was Billy Beane, often thought to be the pioneer in the
trend toward data-driven major league baseball general managers.

I’ve been studying the health care system for nearly two decades,
but I’ve been studying sabermetrics (complex baseball statistics) since
a decade before that. So you’d think that their argument would resonate
with me and, to some extent, it does.

Their thesis is rational in many ways. Much of what is done in
health care has no evidence basis, and we end up spending a lot of
money on things that are unnecessary or even detrimental (or, at the
least, things for which we just don’t know). By developing a better
evidence base and encouraging more use of it, we could improve quality
and lower cost.

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Pitfalls of VIP Syndrome

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By Sarah Arnquist

Slate has an article today by two doctors discussing VIP syndrome in health care and how it can lead to worse care for the rich and powerful, such as Sen. Ted Kennedy, who following a diagnosis of cancer convened his own tumor board.

The authors lay out the pitfalls of VIP syndrome here:

VIP syndrome affects not only treatment but also testing decisions. If
Joe the Plumber requests a CT scan he doesn’t need, doctors simply say,
"No, Mr. Plumber." But Joe Biden can get any CT he wants. Some health
care programs
for corporate executives even involve routine full-body CT scans as
screening tests as part of the "chairman’s physical." The problem is
that these expensive and detailed tests may actually increase the risk
of cancer from radiation exposure
and have never really been shown to improve anyone’s health. And if
there is an incidental finding, as there often is, more tests might be
ordered, which may lead to unnecessary biopsies. And doctors perform
heroic procedures on VIPs not just when there is clear benefit but when there is any question of benefit.

Bob Wachter wrote a few months ago about VIP Syndrome, noting there is a sizable medical literature documenting this shift in practice for the rich and powerful.

Wachter writes, "Every hospital I know keeps some sort of a VIP list, a tripwire to
alert the organization of the arrival of a dignitary or billionaire.
Even when there isn’t a formal list, you can be sure that a single call
to the CEO’s office is more than enough to lift the velvet rope. That’s
a simple fact of life, and to me, not worthy of a big fuss. Unless,
of course, they’re getting better care than Joe and Jane Average. But
are they? Believe it or not, I really doubt it."

Something interesting that both articles point out is that the top researcher or surgeon often directs the care or operates on the VIPs. Often, these top doctors haven’t been in the OR for a long time.

An Impending Hanging: Will Health 2.0 Be Compromised By The Economic Downturn?

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By Brian Klepper

Nothing focuses the mind like an impending hanging. — Samuel JohnsonBrianklepper_2

I’ve been preparing for tomorrow’s 3rd Health 2.0 conference in San Francisco, where I’ll join my pals Matthew, Indu Subaiya, Jane Sarasohn-Kahn and Michael Millenson amid a Who’s-Who cast of health industry luminaries. I spent part of Monday reviewing the attendee and sponsor lists, impressive indeed, testament to how seriously this topic is being taken throughout health care.

The meeting is sold out at 950 participants. It’s worth remembering that, before the first Health 2.0 conference 13 months ago, Matthew, who with Indu took enormous professional and personal financial risk to pull this off, told me he’d be surprised if 75 people showed up. There were almost 500, many of them with genuine influence.

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Using clinical decision support to get the right diagnosis the first time

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Joseph_brittoBy Joseph Britto, MD

Joseph Britto is co-CEO of Isabel Healthcare, a clinical software vendor that helps clinicians with diagnosis. He practiced medicine in the UK before joining with co-CEO Joseph Maude to start Isabel, named after Joseph’s daughter who was wrongly diagnosed with Chicken Pox and nearly died as a result. Joseph has a personal connection as he was the physician in charge of Isabel’s recovery.

Remember President Bush’s goal, first stated in the 2004 State of the Union message, of giving “every American” his own EMR by 2014?

That goal seems as elusive as ever, especially in light of a recently released study by the The Center for Studying Health System Change which found a discouragingly low rate of EMR adoption among physicians. The new study, released last month, reported that only 29 percent of the hospitals surveyed were actively supporting physician acquisition of EMRs through financial or technical support. This number was disappointing in light of the current government initiative that has relaxed federal rules on physician self-referral and made available hundreds of millions of dollars in various subsidies for EMR adoption by physicians.

Many health policy experts believed that “if you subsidize it, they will come.” While that approach has worked in persuading people to take mass transit, it hasn’t lured many physicians into using EMRs.

Why the reluctance? One reason is cost. On September 25, 2008, the Certification Commission for Healthcare Information Technology (CCHIT) issued a report that reviewed 90 EMR incentive programs (state, federal, private) with a total funding of $700 million available.

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Google Health: Is It Good For You?

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By AMY TENDERICHAmy_small

Note: Amy Tenderich, who writes and maintains the wonderful Diabetes Mine,
just did this very illuminating interview with Google Health’s Missy
Krassner.  As you’ll see, she doesn’t slow-pitch to Missy. This is a
sure-footed, tough-minded exchange about the real issues that are on
the table now in Health 2.0. – Brian Klepper

Slowly but surely, using the Internet for your health needs is
becoming as mainstream as shopping on the web: no longer futuristic,
but is it for everyone?  And perhaps more importantly, are mainstream
commercial health platforms from companies like Google and Microsoft
really useful for people with specific chronic illnesses?  I thought it
would be interesting to hear their side of the story.

Missykrasner_3
So please welcome Missy Krasner, Product Marketing Manager for Google Health, whom I was lucky enough to catch up with for an interview last week.

Missy, shortly after Google Health launched last Spring, David Kibbe, former Director of Health IT for the AAFP, noted
that most of its services were “only mildly useful and sort of
‘toyish.’” How have these services evolved to be more useful to people
with health conditions?

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