Here’s a little story from the early days of my first job as a chairman of surgery.
Shortly after I assumed the role of surgical chairman in a community teaching hospital at the ripe old age of 40 and having absolutely no administrative experience, I visited a mentor of mine whom I had known since I was a medical student. He had been serving in a similar role at a larger …
Doctors in no win situations: Damned if you do or don’t
“Here is a prescription for pain medication. Don’t drive if you take it. Call your surgeon if you have a temperature or are worried about anything. Go see your doctor in two weeks. Do you want a flu shot? I can give you one before you leave. If you need a wheel chair to take you to the door, I’ll call for one. If not, you can go home. Take care of yourself. You are going to …
Hospital discharge planning: Involve the patients
Physicians who liberally prescribe empiric antibiotics are often maligned as irresponsible or unthinking by condescending colleagues and policy wonks. But are these doctors actually courageous and prudent, saving countless thousands of lives every year by refusing to bend to misguided pressure from antibiotic-conserving paper-pushers?
As antibiotic resistance has emerged, many hospitals have begun requiring physicians to provide a rationale for every antibiotic dose prescribed. The Centers for Medicare and Medicaid (CMS) …
Doctors who prescribe too many antibiotics: It’s not that simple
More than 80 percent of the United States supply of heparin, a commonly used blood thinner, originates from pigs reared in farm co-ops in China. Farmers scrape mucus from the intestines and send it to central processing facilities, where heparin is extracted and purified before being sold to U.S. pharmaceutical companies.
But in 2007, blue-ear pig disease, causing a respiratory syndrome, became endemic in Asia—leading to a shortage of pigs …
Why the drug shortage is leading to desperate measures in hospitals
I’m always surprised at the number of physicians I work with who worry about, discount, or do not see their relevance outside of clinical practice. I do, of course, recognize their relevance – the trick is to get the docs to.
For many physicians, venturing into positions of leadership, becoming a Department Chair, VP Medical Affairs or even Chief Medical Officer) is a logical step for those looking to expand their skills …
Doctors leaving the clinical practice: The fear of being irrelevant
Last week, I tried something new with our residents. We tried to talk about why physicians overuse tests. This is the topic of the moment, as the American College of Physicians (ACP) just dropped their long-awaited new High Value Cost Conscious Curriculum for what has now been dubbed the “7th competency” for physicians-in-training.
In addition to the ACP curriculum, which I served as one of the reviewers for, I also …
Teaching the cost of tests in medical education
30 day hospital re-admission rates.
It’s a statistic that keeps hospital administrators up at night. Whether you agree or disagree with the use of this statistic as a quality and reimbursement metric, if it creates change, reduces hospital re-admissions and improves patient care, then in theory I support it.
I’m reminded of Mrs G. She is emblematic of today’s chronic disease patient. She was admitted to our hospital for a congestive heart …
Beating the 30 day readmission: Why there’s little to celebrate
Steve is lying almost flat in the hospital room, an IV attached to his arm. I am happy to see he is more comfortable, last night’s crisis has passed. He smiles as I enter and walk to his side. I touch his hand as I sit down on the pressed clean blanket. And then … a shrill loud wail breaks the silence … lights flash above his bed … fear …
Well meaning improvements can hurt critical healing relationships
As doctors in training, we learn to think in patterns of symptoms and can often use “clinical judgement” to fit a patient’s presenting symptoms into a diagnosis. This generally works well, until we are presented with an unfamiliar pattern. For example, in the early 80’s I saw a 60 year old shoe salesman with fatigue and a low grade fever. He had general malaise and some muscle weakness. His exam …
The questions in medicine never change, but sometimes the answers do
I love being a medicine attending in the summer. It’s often more intense work since everyone’s in a new role. Bright, fresh interns. Excited new residents. And the medical students – the new third-year students who have toiled in the classroom finally get to focus on patient care.
Their enthusiasm over hearing a mitral regurgitation murmur, over watching a paracentesis, and, well, their enthusiasm over everything, is infectious. Perhaps it’s a …
Being a ward attending: A job I am so lucky to have
I knew it would happen sooner or later, and earlier this week it finally did.
In 2003 US News & World Report pronounced my hospital, UCSF Medical Center, the 7th best in the nation. That same year, Medicare launched its Hospital Compare website. For the first time, quality measures for patients with pneumonia, heart failure, and heart attack were now instantly available on the Internet. While we performed …
The upside of hospital rankings far outweighs the downside
“I swear to God, if you come any closer, I will kill you,” said the 30-something year old, arms as wide as bazookas, eyes as piercing as the very needles I was about to stick him with. He was hooked up to IVs on every limb, had tubes coming out of his nose and going down his throat, but other than that, he was about as physically fit as anyone I’d …
Learning about patients as a phlebotomist
The ACA passed and is already in trouble. The Republicans are up in arms, calling the ACA an overreach of a totalitarian governmental regime. The Democrats are defending it, promoting its cost-saving measures as a progressive step forward for America.
To say the rhetoric has heated would be an understatement.
I’m not here to debate politics though. In the run up to the Supreme Court’s ruling on the ACA and the recent aftermath, …
A review of NY Med, and fixing health care’s public image
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A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
As a critical care anesthesiologist, I care for patients when they are most vulnerable. Critical care patients require intravenous (I.V.) fluids and medications, frequently through central venous access. These are catheters inserted into larger veins with a special procedure. I believe managing I.V. lines requires procedural skills, …
The role of IVs and central lines in critical care
Chico (all identifying information removed) was a patient we cared for in the hospital.
Admitting diagnosis: “acute kidney injury,” medical-speak for kidney failure. He would need dialysis.
From my point of view–an instructor teaching residents and medical students–there were two key questions about Chico:
1. What caused his kidneys to fail?
2. Given his kidney failure was “acute,” was there any chance that it’d be reversible? Could Chico’s kidneys heal to the point where …
When patients need to find a new equilibrium
“Look left, look right”, our group leader told us. No, I was not learning to cross the street. Rather it was my first day of employee orientation at the IBM Software Lab over a decade ago. I was fortunate that our CEO was Lou Gerstner, arguably one of the greatest CEOs who has ever existed. Gerstner stepped into IBM in the early 1990s when the company was struggling. One of …
The first step to changing the culture in healthcare
The drama surrounding the Supreme Court decision upholding the ACA as constitutional has ended. As legions of reporters and bloggers have written, the law has far-reaching effects. In my corner of medicine it will greatly help (already has, really) a small but not insignificant number of children and families. These families are those who have a child with a severe chronic medical condition. Many of these children spend time in …
How ObamaCare affects critically ill children
Here is the setup. You’re working in the ICU. You want to communicate a prognosis to the family of a patient who is so ill he cannot make decisions. You sensitively state the facts: the patient has less than a 5% chance of survival. Or perhaps you say “he will definitely not survive.”
The family confers, and decides that they want to focus on keeping him alive as long as possible. …
Psychological factors influence how patients interpret information
On the day the U.S. Supreme Court delivered its historic decision on the Affordable Care Act (ACA), aka Obamacare, I was rounding on my hospital patients: a man on the ventilator with pneumonia who had private insurance, one elderly woman with abdominal pain going for gall bladder surgery on Medicare, and one middle aged obese woman with a skin infection without any health insurance.
On my patients’ TV screens I watched …
With the ACA, put politics aside and focus on the facts
Across the country, newly minted doctors have started their internships. The first night on call there won’t be an intern – anywhere in the country – who will sleep. Every new intern is absolutely convinced that the beeper is going to go off and they won’t know what to do. (You get over this by about the 2nd or 3rd call night, by the way).
Graduating from medical school …
Tips to be the best intern you can be
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