Hospital Medicine

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.

A balanced approach to informed consent

Kevin

Patient

February 24, 2011

by Zakari Tata, MD

Informed consent has continued to generate a lot of interest in medicine worldwide.

The reason is because patients in medicine and subjects in clinical trials need protection from the multitude of injuries and harms that have been caused by intentional or accidental actions. The controversies generated by various lapses of informed consent, in my opinion, have not been addressed and more safeguards need to be put in place …

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A balanced approach to informed consent

Physicians who are able to feel compassion

Jill of All Trades, MD

Physician

February 24, 2011

Here’s a true story from the operating room:

Surgeon: Intern, what is the story behind this patient?

Resident Intern: Patient is a 51 year old female with breast lump on the left side, and 17 out of 20 lymph nodes positive for cancer.

Surgeon (speaking in a rather ‘as a matter of fact’ tone): Oh, she’s F_ _ _’d.

Resident Intern: shocked, frozen and unable to respond.

“How do some physicians become so stoic?” I …

Evolution of tablet devices for the hospital

David Ahn, MD

Health Technology

February 23, 2011

When working in the hospital, I intentionally minimize the time I spend on my iPhone because I don’t want people to assume that I’m just checking Facebook or playing Angry Birds.

Even though medical apps and the vast depths of the internet are at my fingertips, it’s just too easy to appear distracted. This represents a subtle, yet meaningful, glimpse of just one reason why I eagerly await the continued evolution …

Tragedy of cancer in a small child

gcs15, MD

Conditions and Diseases

February 18, 2011

The OR was hushed on Friday.

Normally, it is a loud, busy place. The staff and surgeons are almost like a big family; we chat with each other and banter cheerfully with patients to help get their minds off the imminent ordeal of surgery. Chaplains pray with patients and families. Sometimes there are disagreements, as in any workplace. But everyone cares about everyone else.

Because of that caring, it was hushed. Instead …

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Tragedy of cancer in a small child

Every American deserves the right to have a death with dignity

George Lundberg, MD

Patient

February 18, 2011

My old Canadian friend toxicologist Cliff Walberg was right when he famously said, “there is absolutely no limit to how revolting things can be.”

Remember that. It comes in handy, in addition to strong swear words, when stuff happens.

Case in point: I believe that every American deserves the right to choose to have a death with dignity and as pain-free as medical science and practice can provide.

To achieve that, patients and …

ER and internal medicine docs, arguing over a patient admission

Maria Yang, MD

Patient

February 18, 2011

Dr. Erdoc happened to look up when the internist walked into the emergency department.

“Oh no,” he murmured under his breath. The consulting psychiatrist was sitting next to him, typing a note. She looked at him and raised an eyebrow.

“I hoped it wouldn’t be him. Unlike his colleagues, Dr. Internist seems to have a deep loathing for us emergency docs,” Dr. Erdoc explained as he stood up. Dr. Internist was frowning …

The care was futile, and the patient’s wishes

Jim deMaine, MD

Physician

February 18, 2011

“We have a patient on a ventilator here who is stable enough to transfer to your ICU, if that’s OK with you.”

This call, coming from the transfer coordinator, is emblematic of an insurance generated “medical care” coverage issue. I am salaried under the patient’s insurance carrier so the insurer wants this patient back under its wing as soon as possible.

The community hospital has been keeping Stella Norris (not her real …

How medical students should present patients to their attendings

Vineet Arora, MD

Medical Education

February 17, 2011

I just finished another inpatient service stretch at our community hospital with some great cases and lots of good medicine. While attending rounds may have changed a lot in the last 40 years as highlighted in a recent Annals of Internal Medicine article, some things have not changed – the focus on medical student presentations during attending rounds.

Students spend hours through their call nights preparing for …

Let Me Down Easy and facing illness and death

Danielle Ofri, MD, PhD

Physician

February 17, 2011

Every illness is unique, and every person faces illness in his or her own way.

Anna Deveare Smith, in her one-woman Broadway show “Let Me Down Easy,” slips into the persona of twenty individuals who have faced an aspect of illness or death. In ninety minutes, Deveare Smith takes the audience on an existential scavenger hunt, allowing us to observe, and occasionally pluck, insights from this gathering of individuals.

These individuals do …

Time with your patients in the hospital and time with your children

Felicity Billings, MD

Physician

February 16, 2011

As part of the routine scut of the overnight call team, I was sent up to the floor to preop an add-on for the next day’s OR schedule.

The Preoperative Anesthesia Assessment form has tidy little boxes for cardiac, pulmonary, renal, hematologic and an assortment of other complaints, and spaces for height, weight, allergies and personal or family history of untoward reactions to anesthesia. I put a single slash through the …

Hospitals need healthcare flight crews

Kevin

Physician

February 16, 2011

by John LaBine

What are the root causes of communication inefficiencies in hospitals? Hovering around any given patient/case are many players, each with a huge variety of demands for his/her time, attention and presence. And they know there are costs of certain outcomes (medical errors, stress, wasted nurse/physician time, etc.). Each caregiver has his own long list of things to do, places to be, people …

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Hospitals need healthcare flight crews

Teamwork helps doctors with patient safety

Robert Wachter, MD

Physician

February 15, 2011

One of the central tenets of the patient safety movement is that modern medicine is a team sport. Unfortunately, its players – particularly physicians – were trained and socialized to be free-spirited individualists. We need the Celtics of the 80s; what we have is a collection of young John McEnroes.

While this theory has been generally accepted, there is less agreement regarding how to change things. When I speak about Read more…

Teamwork helps doctors with patient safety

Top 5 NICU tips from a preemie parent

Deb Discenza

Patient

February 15, 2011

Heads up folks in the Neonatal Intensive Care Unit (NICU), parents of premature babies want you to succeed more than you may realize. It is just hard for them to communicate this through the fog of stress and exhaustion that has consumed them for countless hours, days and even months.

So here is a little insight into the parent mind and what they want you to know about what it is …

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Top 5 NICU tips from a preemie parent

The hysterical patient during a busy ER shift

Kevin

Patient

February 14, 2011

by VeronicaB, MD

We’ve all had that hysterical patient. The one that comes in during a busy shift. Grabbing at their head, their chest, their abdomen. Yelling out that they are in pain.

You know the one. They makes the nurses’ eyes roll. They add to an already chaotic scene. Other patients stop to watch as the gurney rolls by.

You debate how long you’re going to wait to …

When in the ER with abdominal pain, adjust your expectations

Kevin Pho, MD

KevinMD

February 14, 2011

Abdominal pain is the bane of many emergency physicians.

Recently, I wrote how CT scans are on the rise in the ER. Much of those scans look for potential causes of abdominal pain.

In an essay from TIME, Zachary Meisel discusses why abdominal pain, in his words, is the doctor’s “booby prize.” And when you consider that there are 7 million visits annually by people who report abdominal pain, that’s a …

Why a patient waited 80 hours in the ER for placement

Kevin

Patient

February 12, 2011

by erdoc85, MD

When I arrived for my shift this am, I was passed off the following patient.

EMS responded to a 50-year old guy laying alongside the Interstate. He had no idea who he was or how he got there. He complained of knee pain and shoulder pain. They were kind enough to tote him to my ER where his evaluation revealed that he had a fracture …

The golden hour and the difference between life and death

Kevin

Physician

February 9, 2011

An excerpt from Surviving the Emergency Room.

by Ron Clark, MD

With regard to emergency trauma care, a few minutes can mean the difference between life and death. This first hour of definitive medical care is called the “golden hour.” It is usually this first hour where the patient’s medical fate is sealed. In general, the faster that medical care is rendered, the better the medical outcome will be.

The old adage …

Do stroke centers improve patient outcomes?

Harlan M. Krumholz, MD

Conditions and Diseases

February 8, 2011

Another good paper for a journal club recently appeared in JAMA. What makes this one worth discussing is the research question the investigators posed and how they addressed it. Although this is not focused on cardiac care, the issues are germane to literature in our field and cardiac care certification is also spreading.

The article, titled “Association Between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality,” focuses on the New …

Integrating doctors and hospitals may worsen cost control in health reform

Kevin Pho, MD

KevinMD

February 8, 2011

Health reformers propose the proliferation of integrated health systems, like the Mayo Clinic or Kaiser Permanente, which, according to the Dartmouth Atlas, lead to better patient care and improved cost control.

To that end, Accountable Care Organizations have been a major part of health reform, changing the way health care is delivered.

Never mind that patients may not be receptive to the new model, but the creation of these large, integrated physician-hospital …