Last year I wrote about a few strategies for decreasing costs in the operating room. Since being in fellowship operating many days per week, I’ve come up with a new idea, this time a bit more radical.
In Freakonomics, Leavitt and Dubner posit that in all things, human beings respond to incentives. If you want to understand human behavior, all you have to do is identify the incentives that drive …
Changing the incentives in the operating room
It is almost impossible for me to believe that my views on primary care in the United States have changed so radically in fifty years. When I graduated from medical school in 1961, I was determined to become a primary care doctor. I completed residencies in both medicine and pediatrics to prepare for a career as a general physician in rural Vermont. That dream was put on hold by an …
Looking back at how primary care has changed
My 6-year-old son is really farsighted, and I had no idea. I completely missed it.
To be fair to me and my husband, the ophthalmologist (the esteemed and wonderful Dr. Hunter of Children’s Hospital Boston) said that Liam was compensating really well. And until his yearly checkup last month, he had been passing vision tests (which mostly test for nearsightedness). But in retrospect, there were signs we didn’t pay attention to. …
It’s only through humility that we can achieve great things
“Traveling makes one modest – you see what a tiny place you occupy in the world. ”
-Gustave Flaubert
We have come to Kenya, expecting to work outside of our “comfort zones.”
Our patient has arrived from miles away, riding on the back of her husband’s bicycle. She has an enlarging, bleeding mass growing off of the side of her neck. There are no pathologists available, so we are uncertain what kind of tumor …
In Kenya, operating in our comfort zone
The American public seems to consider cancer and cardiovascular disease in diametrically opposing ways. Cancer evokes the threat of relentless, painful suffering and whatever medical science can do to delay the judgement day is appreciated. Therapeutic regimens may involve disfiguring operations, prolonged toxic irradiation and chemotherapeutic agents that may be beneficial if they do not kill you first.
Response to treatment of limited incidence and duration are accepted and deemed beneficial. …
Considering cancer and heart disease in opposing ways
As I walked up the stairs I thought about the history of the building I was about to enter. Although the foundation was the same, almost everything else had changed. The hallways were updated. The patient rooms decked out with comfortable furniture and fancy televisions. I even marveled at the bathroom as I answered nature’s calling. I could have been in a fancy hotel.
Yes. Things were different than when I …
Can physicians survive the new world being foist upon us?
No matter how quickly you tried to switch the television channel lately, you probably couldn’t escape the trial of Dr. Conrad Murray or avoid hearing about propofol, an anesthesia drug that can be fatally easy to use.
What you may not have heard is that the American people just dodged a serious threat to their anesthesia care, and most don’t know how near a miss it was.
The Centers for Medicare and …
Unsupervised anesthesia care by a nurse anesthetist is a threat to patient safety
Today, during my psychiatry rotation, a very grateful patient confronted my attending and thanked him profusely for saving him. The patient had been severely depressed and was at his wit’s end before they met. The doctor listened to him, analyzed his situation, and came up with a plan to help which included involving the patient’ family as well as using proper medication. The patient had a great response to this …
The hesitation before shaking a patient’s hand in the hospital
I was at the Walter Reed National Medical Center where I get medical care as a retired naval officer, and decided to use my time between medical appointments to get a much needed haircut. I walked into the barber shop, took a number, and sat down to await my turn. The three chairs were occupied by young men getting haircuts. Their chests and lower bodies were covered with long blue aprons to protect them from the …
A cancer survivor’s perspective on wounded warriors
I’ve been talking via email with my stepsister, Lori, whose teenage daughter has Asperger’s Syndrome. Our online conversation was mostly about the highs and lows of raising her neuro-diverse daughter and she shared with me many of the gifts that come along with having a special needs child.
Then, one day, this was the message in my inbox: “Today is a day in the trenches! It’s a battle and I’m bawling …
Your worst days can bring out your best resiliency skills
I recently sat by a man whose young wife was dying. Her cancer was taking her away from her husband and toddler. She was sleeping intermittently as the pain medication we administered did its work. Her husband’s eyes were red from crying and he could barely suppress a sob. He touched her and looked at me. I barely kept my own composure.
I wanted to avoid that room and that patient. …
Medicine introduces us to loss early in life
Until recently, there was a financial difference between performing a “consultation” and a “new patient visit” for office visits (Medicare stopped paying for consultations at a higher rate than new patient visits in 2010).
In specialists’ offices, patients often got billed for the more expensive “consults” when in fact the visit was not a consultation at all. Let’s just use this understanding as the brief background for what I’m about to say.
I …
Billing an established patient visit as a consultation
Cheryl and Susan arrived at the hospital at 6:30 AM. As was their routine, they stopped for their Starbuck’s latte and shared family stories as they walked toward the ICU. The two were well known pranksters but were widely respected for being top notch ICU nurses. The whole crew there was like a family. They went to baseball games, picnics, and vacations together. Today was like most other days. They …
Gallows humor is only a temporary release from a traumatic situation
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Lately, there has been increased emphasis on “preventative” care in the US now that there are some mandates under the Affordable Care Act. The U.S. Preventative Services Task Force (USPSTF) exists, which is a panel of private sector experts who recommend evidence-based preventative screenings for certain conditions based on factors such as age and gender.
As a family nurse practitioner, I base a large part of my practice on wellness and …
Is preventive health really preventative?
I noticed something different about my driving habits lately. At a traffic light I used to accept the green as an open invitation to drive through unconcerned, confident that other drivers would see the red and do what they are supposed to do: stop.
I don’t do that anymore. I always look to see if the road is clear, and other drivers have indeed stopped. And then I go. I have …
In both my driving habits and my surgical practice, I look both ways
When patients are sick enough to require hospitalization, medical decisions often involve nontrivial tradeoffs between risks and benefits. They require discussions with patients and families from a variety of cultures and backgrounds. And sometimes these discussions break down.
Patient-clinician communication is increasingly recognized as an integral part of clinician competency. Indeed, family-centered rounding, increasingly practiced at Children’s Hospital Boston, is a critical step in this direction. Fully adopting this practice surely …
Including communication as a system in work rounds
During my time at PPOH, I spent one day a week working at a geriatric adult home.
An adult home is a residence that generally houses people with psychiatric conditions. They can be run by either public or private agencies. At best, they provide services and supports for the residents so they can live independently. At worst, they provide very little other than shelter; they just take people’s money. (The latter has …
Learning from patients at a geriatric adult home
How long ago was it that we were all content with having the physician have a MD or DO title after their name, the clinic or hospital floor nurse having a RN after her name, the pharmacist having RPh after their name?
Now unless the pharmacist has PharmD after their name they can’t be a pharmacist. And for the nurse, unless they have RN, BSN or RN, MSN after their name …
Let’s stop degree creep in health care
I don’t know when I lost my sentimentality.
Whaaap.
With a thud the fish stops flopping up and down. It lays still on the floor of the boat. My camp counselor, a tanned college student, carefully places the paddle on the seat and cuts the fishing line. The hook remains dangling from the lifeless mouth.
He grabs the fish with his bare hand and throws it back into the water. He talks slightly …
It’s a sad commentary when human beings have to be reminded how to act like human beings, especially when they’re in the helping profession.
Loni Hildebrandt was a 29-year old certified nursing assistant who was pregnant with her first baby. Make that two babies because she was pregnant with twins. Hildebrandt considered her pregnancy miraculous because she had infertility and was a diabetic since the age of one. Together, she and …
When doctors have to be reminded how to act like human beings
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