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Archive for May, 2007

Hospital Night Terrors – Condensed

Max Alexander paints a very frightening portrayal of nighttime in the hospital in the June 2007 Reader’s Digest. There is nothing condensed about the appalling stories he tells which have resulted in death, damage, pain and long term trauma.

The story was forwarded to me by Helen Haskell, one of “us” — patients and loved ones who have suffered at the hands of the so-called American medical care system. Helen’s son, Lewis Blackman, was killed in a hospital in South Carolina by doctors who just didn’t pay attention. Lewis’s experience is one of the stories featured in the article.

Statistics from the article: from HealthGrades – 248,000 PREVENTABLE patient deaths in hospitals in three years. That babies born in California at night have a 16 percent higher chance of dying. That among 15 pediatric intensive care units, children admitted at night were more likely to die within 48 hours.

And weekends are similar — patients admitted to New Jersey hospitals on a weekend were more likely to die within the next month.

And if YOU are the person affected — then the chances of suffering are 100 percent.

Here are some ideas for patients who want to improve their chances of surviving nights and weekends in a hospital:

First — make sure you are admitted to a hospital that allows 24-hour visitation and which will make accommodations for a loved one who wants to stay in the patient’s room. Not all hospitals allow 24 hour visitation, but all of them should. If you know ahead of time that you’ll be staying overnight in a hospital (obviously – in an emergency you may not know) — make sure the hospital your doctor recommends allows 24 hour access to patients.

Second — make sure you know what doctors will be available overnight. One of the problems cited in Alexander’s article is the fact that the hospital pecking order got in the way. Nurses were afraid to call doctors. Interns were afraid to call residents. Residents were afraid to call attendings. Bottom line — you ONLY care about who the attending will be — and — why not ask for that doctor’s phone number? They’ll tell you “no” — BUT — it will show that you are serious about access. Insist on knowing who will be brought in if there’s a problem overnight.

Third — try not to be in a hospital during a weekend or holiday, if possible. Last Christmas and New Years, my mother-in-law was in the hospital. People were nice, but they weren’t very helpful. I still believe the surgery they insisted upon (and which my sister-in-law approved) was wrong and unnecessary. She suffers for it today.

Fourth — if you need to call someone to help you at night, expect they won’t respond, at least right away. That means that whomever is staying with the patient should get to know the staff at the desk — and — don’t wait for someone to respond. Push the button for help, maybe give them a couple of minutes, then the friend or loved one should go out to the desk and ask for help. The squeeky wheel, afterall…..

And if you don’t do all these things? You are putting yourself in jeopardy, no doubt about it. And if you look over your shoulder, you may see all those litigious lawyers, just drooling at the possibilities.

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Primary Care Physician as Care Maestro

When I blogged about your local drug store’s walk-in medical clinic, I promised some thoughts about a shift for primary care doctors and their role in healthcare.

To reiterate: New options for patient care are evolving, and the primary care physician is being left by the wayside. Beyond the walk-in drug store clinics mentioned above, newer “types” of healthcare titles have evolved — nurse practitioners and physician assistants, and these professions can legally and capably perform many of the functions of a PCP generalist. In addition, some patients choose to see specialists on their own without referrals by a primary care physician. As a result of these and other reasons, PCPs are finding the sizes of their practices dwindling, or their time is spent doing more paperwork or phoning and less real patient care. And because healthcare is about money (not health or care) — PCPs are leaving their practices, or choosing to specialize instead.

Talk to med students and you’ll find very few who choose primary care as their field, often because they want to make more money than a generalist like a PCP makes. With all the student loans and effort they put into their education, we certainly can’t fault them for their choices!

It seems to me, however, that PCPs have a major role to fill — and for the most part, it’s not being filled at all. That role is of healthcare symphony leader, the maestro of our care. In effect, the patient care coordinator. Sort of an uber-advocate.

My own healthcare crisis is a good example of stories I hear all the time. When I found a lump on my torso and went to my PCP (actually, his physician assistant) they immediately referred me to a surgeon. The surgeon then referred me to the oncologist. The second oncologist referred me to the National Institutes of Health. When it was all over, and I had figured out I didn’t have cancer at all, my PCP called me and asked me to return to his office to tell him what had happened.

Who was my care maestro? Me! But I don’t know anything about medical anything! I was just determined and angry and confused, and refused to believe that a cancer was going to kill me in six months! There wasn’t anyone with any know-how helping me through the maze. My care symphony was a cacophony of uncoordinated and highly dissonant notes.

How different it might have been had I had access to someone who could have created harmony for my care.

Often, patients contact me with stories that have a similar vein. They are frustrated because there is no one looking at the big picture. There is no one who can help translate what a specialist has just told them. There is no one who can take the test results they’ve gotten from a gastroenterologist to compare to the results they’ve been given by a cardiologist — or whatever other combination you want to throw in. They are frustrated because they have no maestro — no one who is keeping their specialists playing on their same patient page.

Is this not the role of the generalist? The person who can look at the big picture, and coordinate the patient’s care? The person who can be the gatekeeper, the liaison, the translator, the scheduler, the coordinator, the….

MAESTRO?

I realize this is the idea behind managed care. Insurance companies will have us believe, and PCPs will buy-in, to the idea that this is what they are already doing. And, again in my own experience, when it comes time for a check up, then yes, I think this is what happens. As an over-50 patient, my PCP orders blood work, an EKG, a colonoscopy, a bone scan, a mammogram, and then she looks at the results and tells me to lose some weight.

BUT — that’s not what I’m talking about. I’m talking about what happens when a problem occurs. When all is not well with test results. When finding a diagnosis is a challenge. When one doctor is telling a patient to get physical therapy and the next one is saying surgery is the only option. When a man is told he has prostate cancer, but can’t choose between robotic or laproscopic and the only doctors providing advice are the ones who will make money from the procedures.

Who is the care maestro then? No one — because there is no reimbursement for it. The PCP makes no more money once the patient has been sent to the surgeon or the gastro or whoever the specialist is.

There is a huge shortage of PCPs in this country. We don’t have enough pediatricians or geriatricians or those doctors who generalize in order to help people. They are like school teachers; they realize they will be overutilized and under-rewarded, but choose their professions because that’s how they can establish relationships with their patients.

Further, patients are getting more frustrated — and LESS healthy — because they can’t afford to establish those relationships — insurance won’t pay for it. Is this not a detriment to patient safety? Doesn’t this create sicker patients?

Doesn’t this all translate to MORE cost and LESS health?

It seems to me all these disparate aspects of care could come together to benefit us all? What are your thoughts?

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Drug Store Medi-Clinics: How Convenient!

Last evening’s NBC Nightly News focused one story on the medical clinics being set up in drug stores/pharmacies, even supermarkets, across the country. CVS, Target, Walgreens, Rite-Aid — they are all doing it. Included, too, are medical sites being set up by Steve Case’s Revolution program (see previous blogs.) Even AARP has written about them.

The idea is that we health care consumers want and need quick and convenient access to medical care for easier-to-diagnose and treat problems. Instead of calling the doctor for an appointment, waiting at least hours and sometimes days, paying the high price of an office appointment (during business hours, of course!), then having to make another trip to the pharmacy for a prescription — instead we can drop in to the local drug store, sign-in, be seen and quickly tested, then pick up a prescription only feet away and be done with it. Onwards – home to rest, or back to work or school.

The professional staff is usually comprised of nurse practioners and physician assistants, sometimes MDs or ODs. That means you (or your child) will be seen by a professional who can provide a basic level of medical service, but nothing more. If the problem you have is anything more than basic, then you are referred back to your primary care physician (or perhaps a specialist? I’m not clear on that.) The nurse practioner interviewed in the NBC story also stated that all records of the visit are copied to the patient’s regular physician. And, they accept most health insurance plans, so patients pay only their co-pay, as usual.

As your friendly patient-as-healthcare-consumer advocate — I (mostly) love it! It’s helpful, consumer-friendly, inexpensive, convenient and effective.

But primary care physicians aren’t happy with the concept, and yes, I can see a few pitfalls, too.

Pitfalls from my point-of-view are these: symptoms are such squirrely things — with no patient history to review, a walk-in-quick-clinic nurse practioner might not realize that someone’s hacking cough may be something more than a bad cold. Further, one thing I emphasize frequently is the establishment of a trusting and partnering relationship with one’s doctor. It’s those occasional colds, flu and other visits that help us establish those relationships. There’s less of a chance they will develop when patients go elsewhere for the easy stuff.

Doctors don’t like it because it takes money out of their pockets. (yes — all together now! health care is not about health or care — it’s about sickness and money — remember?) They cite the fact that they have expensive offices and staffs to maintain, and that much of the work they do gets done with no way to make money from it (paperwork, phone calls, etc.) They say such clinics will be the downfall of what we know as the primary care model.

My response to that is two-fold. First — patients will always seek the quick fix. PCPs need to see the handwriting on the patient-care wall and realize that this kind of convenient service doesn’t ask them to close their doors; instead it asks them to change their business model. Why can’t they create quick clinics themselves? Or work in one of the drug-stores?

Or — even better — begin working with patients and insurance companies to shift the way they do their work. I’ve identified what I believe to be a huge hole in patient care — and I’ll blog about that tomorrow.

But for now — my advice to patients? Get the care you need in the way that makes most sense, short and long term. If your sore throat or stomach upset or whatever symptoms you have could be the result of something more difficult that a basic bug or infection, then get yourself to a doctor who will be able to see it through with you. A quick fix just won’t be the answer.

But when you or your child needs basic care for those simple-to-fix symptoms – go for it! Much better that you get that care, and get on with life, than to forego care — or languish in a doctor’s office somewhere.

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Depression, Relief and NO DRUGS

After my long absence (moving is SUCH a pain!) I was back in the radio taping saddle this morning. I interviewed Dr. Richard O’Neill about a report issued earlier this month touting psychotherapy (counseling) as the therapy that helped keep 74 percent of those women studied relieved from their depression. The report was found in the American Journal of Psychiatry. If you prefer reading the report in plain English, understandable to us mere patients, try this version from PsychCentral.com.

I don’t usually report on mental health issues. My hands and heart stay full with ideas and commentary about physical health — but in this case, I’ll make an exception, because the role of pharmaceutical drugs is so huge in this report and as we all know, those drugs are intended to alter the physiology of the body.

Here are the basics of the report: 74% of women who were depressed and chose psychotherapy only (NO DRUGS) for treatment, then continued on a monthly basis with their counseling (STILL NO DRUGS) kept their depression in remission. It seems that continuing to discuss their problems with their therapists on a monthly basis kept their depression at bay.

Women who were diagnosed with depression and were treated with antidepressants AND therapy did not have the same result. They continued to need the drugs.

Some thoughts to share:

In our quick fix society, it’s too easy to prescribe a drug that sends someone who may not really need it into a la-la land, where they won’t care. This study seems to say that prescribing the drug to begin with may also doom that person to needing the drugs for the rest of her life.

More and more studies are showing the mind-body connection; that is, that activities such as talking or exercising can affect brain chemistry and raise seratonin levels which elevates the mood. Yet, doctors continue to grab the prescription pad for their patients to supply the quick fix when their patients are depressed or anxious.

Why is it that doctors are not more insistent on providing their patients with different advice — such as referring them for therapy instead of writing a prescription? Three reasons I can think of: First, because they don’t have the training to recognize when a patient needs counseling instead of drugs. Second, because they can’t or won’t take the time to figure out the right avenue for their patients. And third — because insurance will cover the drug whereas it may not cover the therapy.

Sharp patients know that mind-altering drugs, no matter whether they are prescription or illegal or grown in the backyard, can only lead to more problems down the road when they aren’t absolutely necessary for maintaining their mental health. Sharp patients will ask their doctors about therapy when they need their mental status improved and will avoid mind-altering and mood elevating drugs whenever possible.

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