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.

Peer review helps doctors improve medical care

Physician
April 2, 2010

While typing words, the advertisement for yet another hospital is overheard from the TV. “Ignore it John,” I think to myself, but, it is impossible to not look up and see. The head shakes with a smirk, like my grandfather did and without words displeasure was easily conveyed.

Do people really think the graphical professionalism of a TV spot is even remotely an accurate metric of quality of medical care?

At work, …

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Peer review helps doctors improve medical care

Residency training is like James Cameron’s Avatar

Medical Education
April 1, 2010

Dr. Carolyn Clancy, head of the Agency of Healthcare Research and Quality, recently highlighted the definite need for enhanced patient safety and training on healthcare IT for residents who will be the practicing docs of the future.

At the very end, she compared the future of residency training to James Cameron’s Avatar – an epic battle followed by enlightenment.

Because I am a huge science fiction fan and working in graduate medical …

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Residency training is like James Cameron’s Avatar

Teaching patient safety starts in medical school

Physician
March 31, 2010

Ten years after the release of the IOM report To Err is Human, which documented the toll taken by medical errors in this country, the question remains: What can be done to reverse the trend of ever-increasing morbidity and mortality due to medical errors?

Last December, a look back over the decade since the release of To Err is Human — and a steady medical error death rate of about …

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Teaching patient safety starts in medical school

Radiology tests, and how to find their price

Conditions and Diseases
March 30, 2010

I am often asked how we get the prices for the radiology imaging tests, such as MRI’s and mammograms, or ultrasounds. Most people assume that my day job as a doc gives me some sort of special access to this info. But that’s just not the case. Anyone can find out testing prices.

However, over the last year, those of us working at LesliesList.org have gotten more experienced and better at …

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Radiology tests, and how to find their price

Jargon dominates medicine and how doctors verbalize nouns

Physician
March 28, 2010

One of my interns was “running the list” with me last week (giving me a thumbnail update on the plans for each of our inpatients). It was standard stuff until he got to Ms. X, a 80ish-year-old woman admitted with urosepsis who was now ready for discharge. “I stopped her antibiotics, advanced her diet, called her daughter, and YoJo’ed her.”

Say whaa?

I’m pretty sure that the most valuable thing I’ve done …

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Jargon dominates medicine and how doctors verbalize nouns

Death in a hospital is not always comfortable

Physician
March 28, 2010

In America, too many people die in the hospital.

I don’t mean that they die due to medical error or incompetence, though that’s always a hot topic of discussion amongst doctors, researchers, administrators, and regulators.

What I mean is that if you ask most people, they say they’d rather die at home, surrounded by their loved ones, drifting off to sleep painlessly after having had last rites administered (feel free to plug …

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Death in a hospital is not always comfortable

VBAC rates are low, but are obstetricians to blame?

Conditions and Diseases
March 25, 2010

My daughter, who turns two years old in June, is becoming something of a medical rarity. This isn’t because she is showing signs of a late-developing handicap or extraordinary ability for her age – it’s because she came into the world as a vaginal birth after Cesarean section (VBAC), delivered by a certified nurse midwife.

Although more than three-quarters of women who choose a trial of labor over a repeat Cesarean …

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VBAC rates are low, but are obstetricians to blame?

VBAC should not be a woman’s right

Conditions and Diseases
March 25, 2010

VBAC activists are clinging to their resentment and aggressively ignoring reality.

Amy Romano at Science & Sensibility asks the bizarre question: Do women need to know the uterine rupture rate to make informed choices about VBAC? It’s bizarre because she implies that this is a medical question and that the answer is unknown. However, this is a legal question and the answer has been clearly established by the courts. Not …

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VBAC should not be a woman’s right

Futile care has human and financial costs

Physician
March 22, 2010

I haven’t ever saved a life. No doctor has. We may prolong the inevitable, but we don’t save anyone. We aren’t immortal, and weren’t meant to be. We die. All things do. Plants, animals, even stars. Death is as much a part of life as birth. And yet, at times people chase medical science as if we have immortality in all our gadgets and pills.

Why am I writing this?

A few …

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Futile care has human and financial costs

Atrial fibrillation as experienced by an electrophysiologist

Conditions and Diseases
March 20, 2010

Middle age introduces itself in many ways; one is atrial fibrillation. Youth, vigor and a medically-problem free life was seemingly right there in the recent past. A rhythm doctor often hears this suddenness of onset described as “Doc, yesterday, I was fine.” As is always the case for a first episode of an arrhythmia, yesterday, you were fine, but today is indeed a new day.

It happened during a bike ride. …

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Atrial fibrillation as experienced by an electrophysiologist

Medicare rates and capping payments to hospitals

Health Policy
March 19, 2010

If there is anything about economics that has been proven over and over, it is that price controls do not work. The unintended consequences are usually worse than the problem that led to the solution in the first place.

Massachusetts legislators, feeling the frustration of higher insurance premiums, are now considering a bill to limit doctor and hospital reimbursement payments to 110% of Medicare rates, or perhaps some other percentage …

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Medicare rates and capping payments to hospitals

Poetry that your patient can appreciate

Patient
March 13, 2010

When I make rounds with my students and interns, I always try to sneak in a poem at the end. I think poetry is important because it helps convey the parts of the medical experience that don’t make it into textbooks. It’s important because it teaches creative thinking—something of immense value to doctors.

It’s important because interpreting metaphors is a critical clinical skill in diagnosis; patients’ symptoms often present in metaphorical …

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Poetry that your patient can appreciate

Helping organ donation with donor advocate teams

Physician
March 8, 2010

One of the joys of practicing at an academic center is that I get to do many different things in my job.

The foundation of my work is seeing my own patients in a large group (more than thirty doctors!) primary care practice.

Two months a year, I take my turn rotating on the hospital inpatient services, supervising teams of residents and students who are the primary caregivers for patients with illnesses …

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Helping organ donation with donor advocate teams

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Using CT scans to diagnose chest pain in the ER

Physician
March 6, 2010

During residency, there was always a case of misdiagnosed chest pain to discuss in conference.  Incorrectly sending a patient home and missing the diagnosis of cardiac chest pain was an infrequent, but repetitively observed, phenomenon.

So as to tread carefully with words, it is sufficient to say that even now, chest pain triage remains a vexing problem.

Chest pain diagnosis is like appendicitis; there are always small numbers of unusual cases in …

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Using CT scans to diagnose chest pain in the ER

C Diff and antibiotic resistance in kids

Medications
March 4, 2010

A recent story from the UK reported a school child who developed diarrhea and tested positive for C difficile.

The alarming thing is that there did not seem to be any explicit risk factors for this. The appalling thing is the mis-information by the story that, “children rarely become ill with C diff, which normally strikes elderly people in hospital.”

This is how things used to be, before the BI/NAP1/027 bug evolved …

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C Diff and antibiotic resistance in kids

Hospitals can deliver low cost, high quality care

Physician
March 4, 2010

Originally published in MedPage Today

by John Gever, MedPage Today Senior Editor

Many hospitals that spend relatively little per patient deliver good-quality care, researchers said.

Medicare data indicated that hospitals in the highest quartile of per-patient cost for initial treatment of pneumonia or congestive heart failure (CHF) did not have markedly lower readmission or risk-adjusted mortality rates than hospitals in the lowest …

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Hospitals can deliver low cost, high quality care

The Haiti earthquake and its broken health infrastructure

Physician
February 27, 2010

Dr. Barth Green co-founded Project Medishare, which has worked in Haiti for two decades. He led the first team of U.S. physicians to Port-au-Prince after the earthquake and, together with the University of Miami’s Global Institute, spearheaded the development of a 240-bed tent hospital that is now the country’s largest functioning urgent care hospital. His group is working with the U.S. government to establish Haiti’s first rehabilitation hospital. Green …

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The Haiti earthquake and its broken health infrastructure

Can doctors learn medicine from physician lounges?

Physician
February 25, 2010

I just finished rotating at a community hospital where one of the most interesting things I’ve enjoyed is stopping by the Doctor’s Lounge. I can always count on a getting coffee there and hearing some good conversation – doctors asking for input on interesting cases, laughing, sharing stories, both personal and professional, and catching up on each other’s busy lives. In fact, I ran into an old friend of mine …

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Can doctors learn medicine from physician lounges?

Some hospitals tube feed patients with advanced dementia

Physician
February 23, 2010

Originally published in MedPage Today

by John Gever, MedPage Today Senior Editor

Tube-feeding patients with advanced dementia — a practice whose effectiveness has been questioned by two widely cited literature reviews — is most common in larger hospitals and those run for profit, researchers said.

The odds of a feeding-tube insertion in a hospitalized patient with advanced dementia were about 50% greater …

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Some hospitals tube feed patients with advanced dementia

How the ER is now used to triage every patient

Physician
February 22, 2010

The ER is the portal of entry to our hospitals now, for better and for worse.

On the plus side, this means that most patients being admitted to general medical and surgical services have a workup at least started and are triaged appropriately to their destination.

A good ER evaluation should answer the following questions:

1. What’s the nature of the illness?

Are we dealing with the heart, the brain, or an abdominal organ? …

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How the ER is now used to triage every patient

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