Let’s face it. A hospital is a place where nobody wants to be. By it’s very nature, it is somewhere scary and not too nice. Those of us who work every day in hospitals can easily forget this fact: Those who we serve would rather be anywhere else (and so they should). Think of all the things our patients would rather be doing — enjoying a leisurely afternoon with the …
How to design a better hospital
A well-to-do patient recently boasted to me about an expensive insurance plan that he had purchased to “guarantee” that he had access to the best health care in the United States. Coverage included access to elite academic centers (all the usual suspects) and a private jet service for emergencies. He was utterly confident that his investment was worth the price, but I withheld my own misgivings.
Hospital quality data suggest that …
Why an elite academic medical center may not provide the best care
For about 2 years now a tiny ultrasound machine has been part of my standard physical exam tools as I take care of patients in the hospital and in the outpatient clinic. In November 2011, I first picked up an ultrasound transducer in a continuing medical education course on bedside ultrasound for emergency physicians. I am an internist, not an emergency physician, …
Why doesn’t everyone have a pocket ultrasound machine?
We needed to move away from a fee-for-service-driven health care system, where the incentive was to do more to be paid more, and instead move to a system where the incentives are aligned to what we all feel needs to be done.
– Carmela Coyle, CEO, Maryland Hospital Association
Since 1977, Maryland’s unique all-payer system has succeeded in keeping health care costs relatively low. Now the state is embarking on a …
The Maryland approach to controlling health costs
As I walk into the hospital each day, I notice patients and families sitting outside on benches that are surrounded by large signs prohibiting smoking on hospital grounds. For over five years, a collaborative and concerted effort by Memphis hospitals has successfully made all the hospital campuses smoke-free.
Now, in other states, hospital systems like Cleveland Clinic and Baylor Health Care have taken another bold step forward. They have stopped hiring …
Should hospitals discriminate against smokers?
One of my biggest pet peeves is taking over the care of a floor full of complicated patients without any explanation of their current conditions or plan of care from the physician who most recently treated them. Absent or inadequate verbal and written “handoffs” of patient care are alarmingly common in my experience. I work primarily as a locum tenens physician, traveling across the country to “cover” for my peers on vacation …
How to fix the problem of patient handoffs
Recently, the U.S. Centers for Disease Control and Prevention issued two reports that are simultaneously scary and encouraging.
First, the scary news: A national survey conducted in 2011 found that one in every 25 U.S. hospital patients experienced a healthcare-associated infection. That’s 648,000 patients with a combined 722,000 infections. About 75,000 of those patients died during their hospitalizations, although it’s unknown how many of those deaths resulted from the …
There are no quick fixes to hospital-acquired infections
A Southerner at heart, I find myself in love with places. We are forever pining on about our family homes, our small town barbecue restaurant, the sound of some lake where catfish splash in the night, or the woods where our favorite treestand sits. Sometimes our afflictions for place become the stuff of novels; Scarlett O’Hara is always associated with her beloved Tara just as Faulkner is ever infused into …
Hospitals are part of who we are
Earlier this year, I completed a medical rotation in Africa. It was an amazing, eye-opening experience. While I expected it might be difficult to acquire newer, more expensive medications and procedures, I had anticipated that, given limited resources, there would be some rationale in deciding which medications and procedures would be available. I was deeply mistaken in this assumption.
During my time abroad, I watched several patients with heart attacks pass …
Ask if new technology will make a difference in patient outcomes
Hospital medicine has rapidly become one of the largest specialties in the United States. As the number of practicing hospital medicine doctors soars above the 30,000 mark and health care reform takes hold, the specialty finds itself at the forefront of American medicine. And for good reason. It is a young, dynamic, varied and flexible specialty that can be practiced in a number of different settings. Hospital medicine doctors are …
5 ways to improve hospital medicine
Where I’m from, you can have someone killed for $5000. I will do it for $1110. I’m a hand surgeon.
I practice (or practiced, by the time you read this) in an area that is what we often refer to as “underserved.” Rather, the area isn’t, but the people I treat are. I work in a large urban referral center that has a very high proportion of Medicaid as well as …
A patient nearly died to save him $1110
There are words in many languages that have no good English equivalent. During my work in Haiti, I’ve noticed my Haitian colleagues on occasion exhaling a phrase — “tet chaje” — which literally means “head charged.” More accurately, it describes a sense of being overwhelmed or conveying disbelief or frustration. Based on my limited experiences in the field, I can only begin to imagine the burnout that local providers face …
There can be no global health without local staff
A version of column was published on March 5, 2014 in the New York Times’ Room for Debate blog.
To remedy our fragmented health system, reformers want to consolidate health care. President Obama, for instance, has praised integrated health systems like the Mayo Clinic as a model for national reform. To that end, the Affordable Care Act drives more hospitals to become more Mayo-like by purchasing physician practices. Today, about 39% …
Growing hospital networks create a tension for health reformers
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The New England Journal of Medicine recently published an article by David Reuben, MD and Mary Tinetti, MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these “hospital dependent” patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, …
Some people will be hospital-dependent despite our best efforts
Let’s talk internal medicine maintenance of certification (MOC).
I recertified back in 2011, and it was an onerous process capped off with a challenging exam. Thankfully I passed, and I’m good until 2022.
Since then, the American Board of Internal Medicine has made maintenance of certification a more “continuous” process, and is sparking some outcry among physicians. Wes Fisher has multiple posts …
The alarming decline of internal medicine recertification pass rates
The Cayman Islands are nestled in the Caribbean Sea some 430 miles south of Miami. The three-island cluster is known for its inviting coral-sand beaches, laid-back island culture and tax-free status.
While it lures many tourists and big banks, it’s not the first place you’d expect to find the future of American health care. That may change soon.
Last month, I flew to the Caymans to moderate an afternoon-long panel on delivering …
Why the future of health care can be found in the Cayman Islands
The discharge process has now been recognized as one of the most crucial points at which the actions of doctors and hospitals can have a huge impact on immediate health outcomes for our patients. At a time when 30-day readmission rates are still touching almost 20% for Medicare patients, there is an increasingly urgent need to focus on this transition of care point. Discharging a patient is, by its very …
We must place a higher value on discharge paperwork
There’s been a lot of hype about the “Ban Bossy” campaign in the news lately, and the talk is all over the map. I was thinking about it in regards to health care, especially nursing, since nurses are notoriously “bossy,” or at least referred to as such.
I can remember being a nursing student and talking with a physician about a patient during my clinicals. He told me, “You …
Differences between banning bossy and true leadership in health care
Hospitals are environments where emotions can run high. These emotions cross all boundaries and can affect physicians, hospital staff, patients and their families. Dealing with an “angry” patient is a common challenge that physicians face.
The first step for a physician encountering an angry patient is to remain calm and allow the patient to express his or her concerns. In my experience, “angry” patients can be viewed as falling into several …
4 reasons why patients may become angry
One of the most exciting things about working in patient safety and health care quality is that it’s not solely about advancing science or applying performance improvement methods. It is also about the excitement of being part of a social movement that is changing the culture of medicine — putting patients at the center of everything, sharing errors in the hopes of preventing future ones, and confronting hierarchies that stifle …
Introducing yourself to patients is a patient safety issue
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