In about 1985, as I remember it, my training hospital underwent a pivotal change. In Cape Town, at the southern tip of Africa, Groote Schuur Hospital was world famous for being the place where in 1967 an arrogant, brash and brilliant surgeon by the name of Christiaan Barnard stunned the world by performing the world’s first heart transplant. Nearly twenty years later, Groote Schuur (Dutch for “Big Barn”) still retained …
The day our hospital lost its heart
The last four days have provided a sharp glimpse into the future that awaits those of us in the health care profession, physicians in particular. Over the last few years physicians have been burdened with mountains of paperwork, most of which contributes little to patient care, but does take time away that could be better utilized caring for our patients. However, the last four days have demonstrated that the administrative …
Rigid regulation can become detrimental to patient care
I am a third world doctor.
My patients have first world expectations.
Somewhere in the middle, I end up working too hard and then going home feeling cheated. For I too have expectations. I am in a tension between the reality and my aspirations.
In Jamaica, health care is free. Day after day, and night after night its freeness is confirmed, tested. But the system is inanimate. It doesn’t feel its own failure, …
First world healthcare expectations in a third world country
At the University Hospital in Madison Wisconsin in 1938, a patient was dying from a very painful bone cancer which had produced fractures. The young interns knew that more morphine injections were needed but they feared they might be blamed for giving a lethal dose. So a tacit agreement was reached. Every hour or so,one of them would come into the patient’s room and give a shot of morphine. This …
We are seeing more terminal patients being referred to hospice
I’ve been involved in clinical medicine for more than 20 years and during this time I’ve come across numerous situations that created stress, or emotional upheaval within myself, and even times of burnout. At one point, I came close to permanently leaving my chosen profession. The culture of medicine is not geared towards allowing health care providers to de-stress, acquire emotional support, or discuss in an encouraging environment various conflictive …
The culture of medicine needs to change
I recently admitted a patient with a pulmonary embolism. Before heparin drip was started, my attending ordered a hoard of eccentric, non-indicated hypercoagulable workup in the hope of avoiding the effect of heparin on these test results, including phosphatidylserine antibody and methylenetetrahydrofolate reductase DNA. I watched in horror as the nurse drew out approximately 13 tubes of blood, since each test needs its own tube.
On rounds, the attending of course …
Useless thought experiments during medical school and residency
A quality-driven MD colleague writes with frustration about two problems in his academic medical center. I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.
This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for …
Patient safety requires hospital leaders to take personal responsibility
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?
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 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
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
While we are talking about things that drive health care costs up, this one has bothered me since I was in practice years ago. I am a believer in competition, I think it forces us to be creative and provide better, cheaper, more efficient products and services.
But there is the mindset of leadership at play as well. Are we competing to provide better patient services to improve patient care, or …
Why do non-profit hospitals compete with each other?
Recently the Michigan Task Force on Nursing Practice hosted a regional forum in my area. I was fortunate enough to attend and hear from the RN’s there the many issues that they face, which are varied and challenging. The state wanted to hear from this forum of RN’s what changes were needed in the state’s nursing regulations so that certification could be updated to reflect the current nursing environment. It …
Legislating the duties that can be performed by a nurse
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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
Medicare is beginning to tie financial bonuses to hospital patient satisfaction scores.
Although patient satisfaction is important, I’ve voiced concern in the past about giving hospitals a financial incentive to cater to patient surveys.
In a previous USA Today column, I wrote, “already, more than 80% of doctors … said patient pressure influenced their medical decisions. And in primary care, linking …
How patient satisfaction scores reward rich hospitals
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 …
The voice on the phone is demanding, quavering, pleading; “Dr. deMaine you are going to be the attending critical care doctor when our mother is transferred to your hospital today. She needs to be taken off the respirator and allowed to die. We have been pleading with the doctors at the burn center, but they keep doing more procedures. We want her off life support as soon as she gets …
Medicine is slowly facing the issue of futile care
One recent morning, my grandma awoke with abdominal pain. She was taken to a good, local community hospital and diagnosed with acute ischemic bowel. There are various causes of ischemic bowel, but regardless of cause, getting the right care quickly determines whether such patients live or die.
After speaking with her physicians, I called some friends. A quick discussion with colleagues in radiology, surgery, and gastroenterology helped me know that the …
Would patients benefit from experts who never meet them?
My 64-year-old patient with terminal cancer and less than six months to live wanted to go to Oregon. He was contemplating assisted suicide, which is legal there. “My life has been long and good,” he said. “I believe it is my right. I want the ability to say it’s too much, I can’t do it anymore. A person should have a dignified quality of life.”
Another one of my patients, an …
Doctors are reluctant to have end of life conversations
Last year I was assigned to complete a history and physical on a patient in the hospital. Stifling my excitement to be doing this on a weekend night, I walked to the operator’s desk and paged the on-call intern, who — I’d been assured — knew I was coming. “You’re who now for what?” she stared blankly back at me after I’d explained my task.
My patient (we’ll call her Betty) …
A nurse offers a medical student sage advice
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