From your perch in the coffee shop you watch a woman exit the big grey church across the street from the hospital. She’s young, probably not even 40, but she’s dressed like an elderly woman. She’s wearing a shapeless blue raincoat, heavy stockings and wide, steady shoes. Her rosary is looped around her fingers. Across from the church door there is a statue of the Virgin Mary against the fence. …
There’s not much to do but wait
Injury to the brain continues to be a unique thing in medicine. These injuries are scary and unfamiliar to many health care providers. There is a finality to them. Their consequences are hidden a little bit; the asystole is easy to figure in the emergency room but the suppression and brain death isn’t something so easily recognized.
They’re what you might imagine, along with polytrauma, as poster child conditions for tertiarization …
A hospital transfer may not always be a good thing
Six months ago I posted a story about a demented 94-year-old patient who’d fractured her hip. She’d lost more than thirty pounds in the preceding months and had already had a collarbone fracture from a previous fall.
Her son wanted her to be made comfort care only, and avoid a trip to the operating room since she was likely within …
What I’ve learned from calling out my orthopedic colleagues
The Centers for Medicare and Medicaid recently released its compiled data on what over 3,000 hospitals across the country charge for 100 of the most common discharge diagnostic codes under the diagnosis related group (DRG) system, and boy did the DRG really hit the fan. Liberals, economists, and band wagoners got all upset about the enormous pricing differentials between hospitals for the same services.
For example, Twin Cities Community Hospital in …
Are hospitals really soaking the poor with high prices?
Hospitals that are already struggling financially to stay afloat face significant challenges in the coming months and years under some of the provisions of Obamacare.
Under the Affordable Care Act’s Hospital Readmissions Reduction Program, hospitals that readmit certain patients within 30 days of discharge could face significant penalties.
The question is whether hospitals really have that much control over factors leading to readmission and whether they are really at fault.
Some readmissions are …
A more realistic approach to achieving accountable care
I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate.
“The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.
“What exactly were you trying to do before?” some have asked, in that wonderful way …
Quality, cost, and value in health care: How to solve the puzzle
Being a part time hospitalist, I am frequently on overnight call in the hospital, spending the night admitting sick patients from the emergency room, or dealing with any calamities that happen on the medical floors. I would have to say the that the most dreaded events are: “Code blue” (this means a hospitalized patient in cardiac or respiratory arrest waiting to be resuscitated), followed closely by a nurse calling with: …
The spiritual bond between two souls
A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
Thousands of patients undergo surgery every day, but many are unaware how to better ensure a safe and comfortable experience. Too often patients feel like they’re in the passenger’s seat when entering the hospital, even under the best circumstances. When planning to undergo a surgical procedure, with …
Have a safer hospital stay: Use a checklist
How much to treat this pneumonia? The Centers for Medicare and Medicaid took a step towards answering such questions by publicly releasing how much each of 3000+ U.S. hospitals charged Medicare for 100 common medical issues in 2011 and how much Medicare actually paid them.
The charges were remarkably variable, even among hospitals that share a zip code. Massachusetts hospitals tended to charge below the national average (eg. …
An important step toward cost transparency
How do we reduce medical errors?
It’s a question at the forefront of the minds medical and policy leaders today. Entire books have been devoted to the subject, and there is no shortage of suggestions to improve patient safety.
Internist Danielle Ofri recently wrote a New York Times op-ed on the issue, where she reflected on a “near miss” she had during …
To improve patient safety, lawyers need to embrace transparency too
Professions that heretofore enjoyed public admiration for pursuing noble work and reputedly insisting on the highest ethical standards have been exposed. The Catholic church could write a few blog posts on this. Police officers, journalists and even teachers have also shown us that they are members of the human species and are subject to its weaknesses and frailties.
The fallacy is to expect certain professions and professionals to be more irreproachable …
Here are some reasons why physicians lie
If you have been paying attention to US healthcare policy debates lately, you know that hospitals have a price problem. Walk across the street from one hospital to a competitor hospital, and you could easily find yourself facing a $30,000 increase in your medical bills. At one extreme for instance recent information shows that replacing your hip with a surgical implant might cost anywhere from $5000 to …
How Obamacare will largely eliminate price variations
As I began logging on to my third different hospital EHR (electronic health record) recently, I contemplated how much more of this I could take. Being less than a year from planned retirement, the nuances of learning a new EHR and CPOE (computerized physician order entry) system is not fun. Furthermore, every hour I spend learning a new and unique system is …
User friendly recording of data often seems like an EHR afterthought
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To resuscitate or not to resuscitate, that is the question. Whether ’tis nobler to beat the heck out of a person on his or her way out in the hope of saving his or her one precious life, or to allow death to proceed at its own pace with expectation of a peaceful passing.
The United States has come a long way in the last 2 decades since 1991 when the …
Improving informed consent for resuscitation without playing God
In the business of medicine, one of the brightest hopes is the potential for re-optimizing our spend around what patients want. That’s important because decades of research in the field of shared decision making have shown that when there’s a range of options to treat a condition, informed patients choose less spending and less invasive treatment.
That’s a good thing.
Unfortunately, the University of Chicago …
Does shared decision making really increase health costs?
One reason is to apply an extra “facility fee” to patients’ bills.
Another reason is that primary care docs generate a ton of money for the hospital. A new survey was sent to hospital chief financial officers across the nation and based on data submitted by 102 facilities, it found that PCPs generate more annual revenue than specialists do.
PCPs (defined in the survey as family physicians, general internists, and pediatricians) generated a …
Why do hospitals buy primary care practices?
I always believed that, if we could harness the entrepreneurial spirit of the American physician, we could be capable of great things. Physician decisions drive much of what is good and bad about our health care system. Their pens are the biggest driver of cost and their vigilance is the most significant driver of quality. It is a shame that physician-owned hospitals are accelerating the creation of a two-tier system …
How physician-owned hospitals are making teaching hospitals pay
I attended a medical staff meeting recently. These are required meetings and attendance is taken, as was done when we were in kindergarten. While some folks are interested in these meetings’ content, many are not and simply sign the attendance sheet and then slither out in a stealth fashion. Sly doctors grab their pagers and then leave hurriedly pretending that they were summoned to an urgent medical situation, when they …
How the medical profession is being forced to game the system
I must confess that I love my job as a hospital medicine doctor. To me, very few specialties in medicine can be as rewarding as the one I’ve had the privilege of practicing for the last five years. We manage an array of medical illnesses, interact with staff from across the hospital in every different specialty, and follow our patients all the way through their—hopefully very short—hospitalization. We take ownership …
Please don’t call me a hospitalist
I still recall my first rotation as an inpatient attending at Memorial Sloan-Kettering Cancer Center (MSKCC). Perhaps it was the anxiety that I remembered most; that I was “in charge” of a service. Fortunately, having done fellowship at MSKCC, the system was not a foreign one, and I knew exactly where to go to get oriented—I went to Jane and Dorothy, …
Why I rely on non-physician providers
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