Physicians writing on KevinMD about hospital practice: employment by health systems and corporate owners, hospital closures after debt-financed acquisition, productivity quotas, the electronic record as hospitalists live with it, from alert fatigue to copy-and-paste, the errors hospitals count and physicians remember, and the nurses physicians work beside. Four maintained records draw on this archive: Private equity and corporate medicine: what physicians say, in their own words, The electronic health record: what physicians say, in their own words, Medical errors: what physicians say, in their own words, and Nursing: what nurses and physicians say, in their own words.
I had just put him on a ventilator. Mr. Barnes (not his real name) had come in by ambulance sweating, barely responsive, gasping for air. The paramedics said he was from the local rehabilitation hospital and had just been sent there 2 weeks ago after a protracted hospitalization for a stroke which had left him partially paralyzed. Then they showed me medical orders indicating that he was “full code,” medical …
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5 questions to change your end-of-life path
Local hospital readmission data mirror national data in that twenty percent of hospitalized patients are readmitted within 12 days of discharge, and 30% within 30 days. Hospital reimbursement has changed to global, not fee for service payment. Hospitals and physicians need to create effective ways to prevent readmission. Readmissions also portend poorer outcomes. Therefore, it is our task as the physician community, to work collaboratively in this process.
Currently, most patients …
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Why reducing readmission rates is so difficult
We’ve come to a sorry pass in American medicine when physicians are willing to spend a lot of money to attend conferences—not to learn how to become better physicians, but to find a way out of the pit of clinical practice.
Few of us have the charisma (or chutzpah) to make a living in medical show business, like Sanjay Gupta or Mehmet Oz. But apparently any physician today can be clever …
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Is not seeing patients the answer for many doctors?
Some time ago, I endured a medical staff meeting, where attendance is taken and 50% attendance of all meetings is required. I learned that they are serious about this rule when, a few years ago, I was demoted from active staff when I failed to attend enough meetings. This demotion did not demoralize me, as I was only losing my right to vote, which I did not regard as a …
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Contaminating medicine with mercenary incentives
“Educate the young, regulate the old.”
That quote has literally followed me around the world. I can vividly remember when first making the statement. I was one of five “safety experts” on the closing panel at an international safety and quality meeting in Sydney, Australia a number of years ago. The thought was that the five of us would somehow be able to share “pearls” of wisdom regarding what was …
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How to improve physician compliance
All of us hate waiting in lines. Our society breeds a “me-first” attitude. Often the lines in which we wait are slow to move and, we become irritable and angry. Somehow there is always someone who is able to outsmart the system and get served ahead of their place in the queue. In the typical queue at the grocery store, (or at the apple store genius bar) we become impatient because …
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How families cope with the surgical waiting room
Stranded capital is a new term, a derivation of the term stranded costs that emerged from the deregulation of electric companies. It refers to “the existing investments in infrastructure for the incumbent utility which may become redundant in a competitive environment.” Many academic medical centers are weighing the importance of meeting current demand while considering the risk that, in a future competitive environment, dramatic declines could occur in the need …
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Do we have too many hospital beds?
I could hear the morning call to prayer as I drove toward the Aramco Hospital in Dhahran, Saudi Arabia for my early morning rounds in the ICU. I was hoping that my young asthmatic on a ventilator might be ready to be weaned off and that the medications had kicked in sufficiently. My young Saudi medical student met me on the way in and said, “I think she’s doing better, …
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Caring for the patient despite a vast difference in culture
I’m sweating and silently wondering how the chewing gum in my mouth has chemically changed to sand. My mouth is so dry I can barely speak. I may be silent, but thank goodness my patient is talking to me, because all his monitors and machines seem to be bleeping and bopping and malfunctioning at once.
I reach for my eyeglasses, which have become hopelessly entangled among pens, alcohol wipes, and other …
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When teamwork takes more than the usual share of effort
While there is an extensive literature on how tired, overworked physicians provide lower quality medical care, one thing that has been ignored by advocates of quality improvement is that overwork financially harms hospitals as well. Just as tired physicians sometimes fail to attend to certain clinical details, they are also more likely to commit errors when writing the notes which ultimately are used during the coding process. If hospitals consider …
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The influence of fatigue on claim quality
One of the most memorable discussions regarding the cost of care was at 4:45AM during surgical morning rounds.
As usual, the interns would present the overnight events of their patients to the chief resident and a plan for the day would be agreed upon. These morning rounds were particularly intense: in addition to the 30 patients that an intern had to manage solo over night, the brutal hours that the surgical …
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Is the daily blood draw in the hospital truly necessary?
I am four months into my third year of medical school. The third year is the first clinical year, when students spend most of their time in the hospital, interacting with patients and working as part of the medical team.
Our deans told us at the beginning of the year that we would be talking with patients more than anyone else on the medical team; we would serve as advocates for our …
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As I progress through my medical career, I must make time to listen
Any new technology necessarily has a phase in which unnoticed bugs as well as unforeseen challenges crop up. In its early stages, the snail’s pace of a dial-up connection often made using the Internet onerous: before completing an email, one was often interrupted by pop-ups, viruses, cryptic 404 error messages, and a cacophony of sounds from the modem as the line repeatedly disconnected. Yet, as technology matures, the ability to …
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We must get past the complaints doctors have about EMRs
The show-stopping line from the Hans Christian Anderson’s 1837 fairytale is actually, “But he has nothing on!”
A brave, young, clear thinking boy in the crowd is the only person confident enough to say what he thinks and speak up. Perhaps even more simply, the young voice in the crowd has not had the life experience that often builds (and rewards) the filters of loyalty, flattery and only saying and thinking …
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How we need to take risk to reduce risk in hospitals
April 15th marked the 100th anniversary of the sinking of the Titanic, yet the mystique surrounding its demise has not faded. When the colossal vessel first collided with the iceberg, eyewitness accounts described an eerie sense of serenity that pervaded the ship. Passenger J.J. Astor even remarked, “We are safer here than in that little boat,” before later drowning.
To prefer drowning over safety strike us as irrational, but this behavior …
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What medicine can learn from the Titanic
On a late afternoon in mid-July I was finishing up my first Sunday on call as a third year medical student. I glanced over the patient list for 4 East, the internal medicine floor I had been assigned to cover. Familiar with patients in their eighties and nineties, I was surprised to see a 22-year-old patient admitted with acute kidney injury.
He was a nice-looking young man in good spirits. Spanish …
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Failure of communication led to an excessive hospital stay
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