A Technique for "Road Rage"

Road Rage an aggressive or angry behavior by a driver of an automobile or other road vehicle.  These behaviors could include rude gestures, verbal insults, deliberately driving in an unsafe or threatening manner or making threats.  Road rage can lead to altercations, assaults, and collisions that result in injury or even death.

A simple technique to combat road rage or any stress is Pranayama breathing.  Pranayama is a Sanskrit word meaning extension of the prana or breath- extension of the life force.  It is a yogic discipline with origins in ancient India.

A simple form of this breathing is a long 3 second inhale through the nose followed by a long 3 second exhale through the nose.  Easier said than done.

One of my yoga instructors stated that in 12 seconds- 2 complete breath cycles- one can eliminate stress and hostility.

The next time somebody cuts you off in your car, try 1 breath I, 1 breath out, 1 breath in, and 1 breath out.  You will be surprised by the power of the breath!

Is It Time to Start Downsizing?

The author of 12 Changes That Will Affect Doctors' income in 2015 lists major changes that should have a net negative effect on providers’ incomes due to the Affordable Care Act. I suggest you read this article.

 

1.      High deductibles is the new self-pay in disguise with many patients not aware of this serious issue.

2.      Decrease in malpractice premiums which will probably be a transient benefit. Caps are being overturned or litigated in most states.

3.      ICD-10 will begin in October and the true cost is not yet known. Most experts think practices should have a 90 day reserve fund to make payroll.

4.      Practices involved in Medicare Accountable Care Organizations will be losing their guaranteed contracts to avoid losing money. There is a bill in congress to keep the contracts viable for 3 more years. Not sure what will happen in new congress.

5.      The emergence of Telemedicine is affecting the growth of certain practices. The reimbursement for these services are still be battled over. The legal liability is also in flux.

6.      Retail clinic pharmacy driven practices are direct competition to the standard practitioner.

7.      Primary Care Physicians will lose their enhanced Medicaid payments. These payments will lower back to approximately 40 cents on the dollar.

8.      Meaningful use become more “mean” and will now penalize rather than reward the practitioner.  The government wants its money back.

9.      PQRS will no longer give maintenance of certification monies for meeting quality measures. Penalties will ensue.

10.   Medicare payments to specific providers are now available without context on new websites.  Bad publicity is the net effect.

11.   Medicare will start paying for chronic care outreach to providers who deal with patients with 2 or more chronic conditions. The downside is the necessary documentation to avoid future audit.

12.   New CPT modifiers to replace the 59 modifier for procedures. Make sure your billing team is ready to change. Failure to act will lead to another excuse to deny or delay
CLAIMS MADE.

 

Welcome to the electronic age to save Medicare money. These trends are just the beginning to try to save Medicare. Cost shifting to the provider is an easy route because they are all “rich doctors” anyway.

Fighting the Most Common Chronic Financial Illness

Chronic illness is a long-lasting condition that can be controlled but not cured. As described by the Centers for Disease Control, chronic disease is the leading cause of death and disability in the United States.

In financial terms the most common chronic illness is the “Disease of Fixed Expenses”. This affects all demographics and incomes. It is the never ending list of payments and obligations that one accrues through ordinary life. It becomes an acute illness when the “patient” gets ill, fired, laid-off, and or retires where the monthly income is significantly reduced or eliminated.

This can be controlled through conscientious budgeting, but this is not in the nature of 95% of the population. The advice is always the same- Save, spend less, avoid immediate gratification, have a plan, etc., etc.

This advice is always in a vacuum that doesn’t take into account the pressures to spend by family and friends is endless. The most organized and frugal person may not control their dependent group leading to a feeling of hopelessness or just “going with the flow”.

Some easy suggestions to ameliorate the problems.

1.      Anticipate that house payments, car payments, insurance payments, and tax payments never go away.  Realize that the most expensive house and or car is not necessary and these possessions are only tools. After a couple of years, the $25-40,000 car gets you to the same location as the $60,000 vehicle. The more expensive car with insurance, maintenance et al costs over $1,000 per month for 5 years.

2.     Discuss money with your family/dependents and carefully explain “how much a broom” costs and come up with a reasonable spending approach. Let them make compromises to get what they want.

3.     Realize you are getting older, and basing your “happiness” on things is misguided and driven by television and movies.

4.     Avoid being jealous of another’s success.

5.     Stay healthy and avoid medical costs.

6.     Anticipate unanticipated disasters – things are going to happen; face it. These characteristically require significant expenditure, often all at once, and often without time to develop a less costly strategy. Thus, planning for, and having an account with, say, $100-$150K, set aside only for emergency purposes, is wise.  If you do, there are several principles: don’t touch it for anything but an emergency; never borrow from it thinking you will repay (shortly) in the future. You won’t. Are you wise?

 

These may sound preachy but I am guilty of all these sins and now realize the shortsighted of my lifestyle decisions.

Making more money does not improve the condition, it only changes the paradigm. More money=More expenses=More Fixed expenses.

 

"Melting" Your Aches and Pains Away

My spouse recently started a new program called the "Melt Method" to achieve flexibility, relaxation and pain relief.

The self-treatment system claims to restore the supportiveness of the body's connective tissue to eliminate chronic pain, improve performance, and decrease the accumulated stress caused by repetitive postures and movement of everyday living.

Benefits include:

Improves

• flexibility & mobility
• posture
• results of exercise
• range of motion
• sleep & digestion
• overall well-being

Reduces:

• aches & pains
• wrinkles & cellulite
• tension
• headaches
• risk of injury

Does it work in real-life?  It essentially functions a directed self-massage techniques that involves using soft rollers, acupressure-type balls for hands and feet, and stress reduction attempting to improve one's general well-being.

My wife and friends claim they are 1-2 inches taller and stand up straight after a standard class.  Wanting to take a peaceful nap after the sessions is a side effect.

As one ages; stiffness pain, loss of flexibility, balance, and loss of range of motion become the reality instead of the exception.

At present my wife is involved in Yoga, TRX and the Melt Method and the combined results are pretty outstanding.  My suggestion is you might add this to your regimen.  It is a great substitute to using medications to treat chronic pain.

I recently went to a James Taylor concert and the crowd looked like (myself included) an AARP convention.  The majority could have used a physical and mental health program to walk up on down those steep stairs.

Screen Savers as a Communication Tool

Almost every medical facility has multiple computers at multiple work stations. Each computer has a screen saver that is usually a name, advertisement, and or picture.

With the recent confusion at the Texas hospital about Ebola, it is a simple tool to enhance communications throughout the institution. Some hospitals have already posted announcements and schedules of meetings on them.

The next step would be to use the screen as a notification tool to all the staff.

1.      Infectious disease updates:

a.      Fever, Travel, and/or exposure to traveler to West Africa: Contact Physician and Nurse Supervisor Immediately.

                        b.      Children with shortness of breath may have serious Enterovirus.

                        c.      Influenza season starting: Get your flu shot, please:

                        d.      CDC warnings

2.      Meeting or Activity notices:

a.      Joint Commission here Mon-Fri

                        b.      Blood Bank drive Friday.

                        c.      Hospital wide meeting with Leadership on Tuesday.

3.      Drug shortages:

a.      The list is endless

                        b.      Substitutes available

The utility is endless and can be easily programmed. Different computers with specific target audience can get different messages.  Add the screen saver as part of your system to ensure that everyone hopefully knows what is going on.

Instead of being reactive, this is a proactive step.

Tyranny of the 24 Hour News Cycle

It does not take a university level course on marketing to see that news sources are more truthfully in the business of entertainment than in the business of accurate information dissemination.  If a “story” excites, titillates, captures the mind, it is successful, despite its truth.  To observers, the current mode of public information distribution seems more like onscreen supermarket tabloids than the down-to-earth news given by respectful predecessors like Walter Cronkite, Jules Bergman, Chet Huntley, and David Brinkley.  These days, entertainment trumps accurate reporting.

            The problems inherent within an insatiable need for more information at breakneck speed include lack of verification, HYPE!, misinformation, professional “talking heads,” speculation without sufficient data, and the race to be “First”.  After all first-and-foremost means top entertainer.  The list of such inaccuracy generating issues could go on and on.

            In the 24/7 cycle, people or perhaps institutions are blamed or praised at the outset, according to the political bent of the station. Then, political correctness (either right-wing or left-wing) is added to the mix; now we have an attention-getting story that can be repeated every 15 minutes for 24-72 hours or until some new disaster pops up.  Advertising is sold hand-over-fist according to the ratings that any news show gathers through it’s stage show.

            The Texas Hospital Ebola exposure presents a good example of how the blame game feeds the fire of the news-show/entertainment industry. Here, the hospital, nurses, physicians, Emergency Department, Electronic Health Record, Homeland Security,  and the TSA were all good candidates to blame, and each was hit sequentially according to the texture of the moment. Rather than taking a systematic review of the entire process, a tangible scapegoat was needed, and someone, some individual, had to have failed, rather than the system as an interconnected entity. However, this was instead, a system failure. When you blame an individual for a system problem, finger pointing immediately occurs. “It was not my fault, but was a result of someone else’s incompetence (certainly not mine!).”  That generates interest, attention from the masses, and channel habits, being psychologically less boring than saying “Hey, look, the system just failed.” There is nothing more dull or tedious for the human psyche than to have no one to blame.
            Gun control, abortion, immigrations, health care, race, and welfare stories always lead to an immediate pro or con response without analyzing the individual merits of the case. For the sake of the modesty of this blog, nothing further will be said regarding the visual appeal of the female news anchors that always seem to appear.  In real life, there just are not that many scantily dressed beautiful women in one place. Seriously? There must be an average looking female journalist somewhere.  But, after all, entertainment is entertainment.  Just saying.

            As one watches Fox, CNN, MSNBC, PBS, and any number of other news stations, their political viewpoint is easily ascertained. Depending on the channel, the CDC was either on top of the situation or “hiding the truth”. Even with talk radio, expected to be along partisan lines, it is easy to hear an underlying “chronic agenda” that is hardly impartial.
            In conclusion, the massive appetite of the 24 hours news cycle does not reflect an overall common sense collective approach to solving problems. Information, provided in this way, and blanketing the media, is thus a major contributing factor toward the endless divisiveness in our society. Would it not be healthier to allow the average person to sit on different sides of an issue, even retaining a bit of ambivalence, without the inherent name calling that derides an absence of political correctness from one or the other perspectives. Occasionally, a reasonable compromise can be a good thing.

The Ebola “Shake”

As the Ebola epidemic shows no signs of dissipating, it is probably time to change some common greeting customs. The standard greetings depending on location, culture, and state of intoxication include handshakes, hugs, kissing both cheeks, chest “bumps”, high five, low five, and multiple variations on above.

 

               With skin-to-skin contact, spread of the virus is possible but unlikely, as the infected contact is thought to require high illness severity accompanied by a high viral load.  To avoid transmission, but continue the formalities of social greeting, the suggestion has been made to switch to the lightly closed fist “hand-bump.”

               There are two variations of this:

1.      The covered hand (where you pull your clothing over your fist and then make contact.)

2.      The uncovered hand where you feign actual contact, gesture, miss, and retain the psycho/social effect.

The Japanese culture with traditional bowing has already solved this dilemma. Not sure that this will translate to a more macho western culture.

               There has been much controversy in the news media about the proper way of avoiding the spread of Ebola worldwide. The options of travel bans, closing air traffic, quarantine, and testing stimulate expert opinion. These expert opinions are extremely varied and seem to be based on political orientation to avoid panic and medical need according to the CDC based on medical evidence according to epidemiological techniques. At the present, there are shifting recommendations on a daily basis.  The 24-hour news cycle, political correctness, and true lack of knowledge makes it look like there is no black or white answers.

               In large part, these shifts reflect an imperfect science regarding the transmission of this virus.  The ease with which it spreads in some situations (e.g. to healthcare workers) is offset by a variable period of contagion (thought—but not guaranteed-to maximize at 21 days), an ill-defined onset of viral shedding (headache? myalgias? rhinorrhea? low-grade fever?), a degree of permeability to protective gear that is almost uncanny, as well as an unknown capacity to mutate and circumvent measures being established.

               Moreover, effective treatment is now generally agreed to depend on one dimension:  supportive care with adequate hydration and electrolytes.  It is almost cholera-like, and electrolyte depletion is now thought to be the final common pathway to death.  Quite likely, when the analytics are complete, they will show that most of the deaths in W. Africa could have been prevented with simple IV hydration.  Not to mention that much of the transmission there could have been averted by common-sense burial practices*, along with mitigation of unnecessary fear.  Yet, in those countries, at the height of the disease, those infected (including many healthcare workers) were sent to the back (rooms, tents, fields) and left alone, where they, of course, died.  Treatments such as convalescent serum, plasma, ZMapp were, in all successful cases, given along with good supportive care, and full hydration. Hence, it was, to any cogent medical mind, the hydration and support that made the difference.  Since cases are now being shown to recover just with fluids, the other “treatments” were clearly superfluous.

               The probable truth is that there are no straightforward solutions to the problem of stopping transmission.  They become, and are becoming more and more, epidemiologic and political decisions.  The common sense approach of attacking and isolating the problem at the source through quarantine and support sounds the best but may not be the whole answer.

               The Ebola epidemic will ultimately probably be controlled or burn-out itself and life will go on. In a prior blog (Life Imitates Art) it was stated that is really hard to get things right without the necessary experience. The fact that multiple communities and countries are trying different things will allow the analysts to come up with a “game plan” in the future for the next uncontrolled world-wide pandemic.  We should consider the present infection as a “test” of our preparedness and make the appropriate adjustments.

*In one well-known case, when it was thought the outbreak was just about under control, the body of a woman who died from Ebola was taken from the hospital under gunpoint by relatives.  Her remains were taken to their home, and the practice of full contact mourning caused a resurgent outbreak in the area.

When Life Imitates Art

There is a television show called “The Strain” a television series that premiered on FX on July 13, 2014.  It was created by Guillermo del Toro and Chuck Hogan, based on their novel trilogy of the same name. The show depicts a vampire-type apocalypse that when superimposed on the “Ebola Crisis” have very similar characteristics.

In the show the “infection” which leads to a form of vampirism has the following characteristics:

1. The illness arrived by plane.
2. The illness is spread by direct contact.
3. The illness is contained in a “wormlike parasite” which looks very similar the electron microscope pictures of the Ebola virus.
4. The victim proceeds to transmit the illness directly to their immediate contacts (the people they love).
5. The Centers for Disease Control are both the heroes and villains.
6. Decisions about protecting the community are a complex interaction between fact, fiction, political issues, financial issues, and last medical issues.

It is interesting the parallels and if one get rid of the vampire stuff, pretty close to reality. These are complex problems which hopefully will get sorted over time.

The recent admission of an Ebola victim to a Texas hospital has created a furor in the media but how could the Emergency Department send someone home with “fever and feeling bad.”  The blame game started with triage nurse, the Emergency Department, the hospital system, TSA and Homeland security, and now the Electronic Health Record for not identifying this problem the first time.
Before everybody gets upset, the reality of Emergency Medicine is that it is traditionally a reactive specialty that once it identifies the specific threat it is nimble and organized to create policies to avoid missing the next case.

The Texas hospital had the misfortune of being the first place known to have had an Ebola exposed patient leave the department without initially identifying that individual and setting the “government” machinery on them.

The individuals involved unless prescient are victims of a system error where the safeguards were not already in place. The institution having no experience of what to look for probably were not geared up. The Electronic Health Record and clinical decision support (artificial intelligence) is probably not geared up to give the providers adequate warnings.

Blaming individuals will not solve the problem, but a plan to be ready for the next case is the proper pathway. These are “system issues” that require an organized response. Vampire shows are not for everyone, but sometimes they are well-made and interesting.

Is There a 'Black Box' In Your Future?

The article Does a surgical 'black box' open the floodgates for malpractice suits? reports that a Canadian team of surgeons is creating a black box for surgery similar to aircraft. 

In ancient times surgeries were viewed in a theatre where one could watch and learn.  However, most surgeries today are isolated to the direct participants.  The black box would give a real-time analysis of surgical performance, errors, and endless feedback.

The problem is not the data itself, but potential downside use of the data for malpractice litigation.  Most surgeons of course, would avoid adding suit-risk to their practice, if indeed litigation is the use that is given the most press.  Yet it is sad to ignore the potential of such devices that have potential clinical application in many other settings, such as in the emergency department and heart catheterization lab.

The use of the term black box is a bit Orwellian.  We are not in 1984 and most physicians, even may surgeons, recognize the value in real-time feedback.  Being human, mistakes happen, and any device that enables more comprehensive observation of the care process, giving guidance when needed, will be well appreciated.  BUT, that appreciation will disappear, if the name black box is used or the look over your shoulder aspect is the one that is emphasized.  Even may p-to-date cars warn drivers of impending accidents.  Why not offer the same technology in the surgical suite?  As with most innovation, the devil is in the details and marketing of such products is key.  These provide feedback in a manner no different from any other clinical decision support (CDS) device.  Advice from a CDS system can be either accepted or rejected, and the ultimate responsibility remains that of the physician in charge.

Similarly, the advent of Google Glass, with its ability to record every viewpoint, is in the same vein, ad may make the concept of the black box already obsolete.

What will surgeons do?

1. Resist, if able
2. Perform only life-threatening surgery in these arenas
3. Try to perform most surgeries in a Surgery Center

These are doubtful.  Most likely they will initially explore, then comply with whatever mandate requires use of real-time feedback technology.  Indeed, providers may be forced to behave as if always on camera (and that may be a good thing).

Real-time Emergency Medicine with Google Glass Technology

Google Glass is a definite leap toward the inevitable future of direct mind-CPU integration.  One does not have to be a crystal-balling futurist to see that surgical chip implantation in the brain is not too far behind.

The article Google Glass May Help Emergency Physicians Improve Patient Care identified potential uses of the device in tracking, decision support, and diagnostic aid (the first tricorder).  Of course, fans of the science fiction series Star Trek, know that a tricorder is a hand-held multi-function device that Doctor McCoy depended on for sensor scanning, data analysis, recording data, and more importantly diagnosis.  During the years the original show ran, most Trekies could not even imagine the wireless world that we have now become so accustomed.  Nevertheless, it does not take much further imagination to conceive of a medical world in which past records, CT results, lab data, immediately visualization, and decision analysis all wirelessly get synthesized and collated through a common central device, such as Google Glass.  Hence, what was once science fiction is now considerably closer to science reality.

An especially intriguing potential use for Google Glass is real-time supervision and consultation.  As the number of Nurse Practitioners and Physician Assistants increases, the need for careful monitoring increases.  Thus when supervision is enabled in real-time, the system will experience delivery of coordinated care that is inherently more safe.  For academic organizations, think of an attending being able to effectively supervise more residents than could be possibly be achieved by walking from bed to bed.  And then, even in our own practices, a cardiologist might review an EKG as it is actually taken, through the device at the same time as you, naturally speeding up disposition.  The list of conceivable benefits goes on and on.

With the ability of the Google Glass to take photos and record evaluations, the encounter itself, as well as its related data can easily be transmitted to a person who may be in charge.  At the same tie, the accuracy and quality of care can be monitored and expertise and assistance, when needed, can be given immediately.  Of course, there will be some naturally expected barriers to full adoption, not the least of which will be the necessity of acquiring experience, along with the need to promote an atmosphere of cooperation among practitioners, where guidance is seen as providing real-time feedback and advice, and not as demanding or disparaging.

Additional benefit will arise if this technology enables the staffing of facilities with fewer high level and therefore more expensive individuals.  One might ask: how many physician will be needed to staff a 60,000 visit emergency department in the world of the near future?  Currently, general wisdom says one would need 12-16 physicians and 8 supporting PA and/or NPs on a full-time rotation of shifts.  One can anticipate that the balance within this ratio might well change in a Google Glass supported ED, requiring less physicians and facilitation the use of more support-level practitioners.  The Glass might enable the eyes of one ED doc to roam much further than before.  such a far-reaching vision would also be a great benefit to rural hospitals and locations that find it difficult to attract physicians, since observational immediacy could be obtained without physical immediacy.

Glass data could be sent right to the consultant to help clarify, expedite, and provide hopefully better care- how Trekies is that!  It promises to have an equally strong real-time presence in the documenting and decision-making process.  The Google Glass linked EHR of the future can well be envisioned as documented by a reviewable folder of commentaries, snapshots, an videos of what occurred.

Of course, the tricorder will not put health-care providers out of work because you will need someone like McCoy to say to the captain: "Dammit Jim; I'm a doctor not a ...!!!"

Doctor Errors Kill 500,000 Americans a Year

The article published last week the author claims that Doctor Errors Kill 500,000 Americans a Year. 
The Institute of Medicine in 1999-2000 released a report that 44,000-98,000 patients a year die as a result of medical errors.  The main categories of error at the beginning of the 21st century were diagnostic, treatment, prevention and system errors.

 

In this article, only about 15% of a decade later, raises that number to 500,000.  Is 500,000 accurate?  Well, that depends on how the counting is being done, as it is an inherently complicated analysis to determine whether "a specific action or inaction directly lead to a death".

 

 

Causality: is the relation between an event aka the cause and a second event aka the effect, where the second event is understood to be a consequence of the first.

 

A chief aspect of the complexity is the blur that naturally occurs between events that are simply associated in time, and events that are causally linked.  When events are merely associated with one another, they may appear to be causally linked because one comes before, and the other occurs after, but causation is nevertheless absent.  When events are actually linked by causality; however the earlier produces or directly contributes to the later.

 

Sorting this out may seem achievable, but often is not.  moreover, for the purposes of health-care analysis or litigation, it is quite easy for one side or the other to make before-after appear like before caused after.  When cause and effect are obvious then the attribution of causality is clear.  Usually this only happens in simple cause-effect circumstances.  Say a person weighs 500lbs and is known to have eaten three gallons ice cream nightly for the past 15 years.  In this care, the cause-eating ice cream- is certain without any doubt.

 

But in medicine, things are rarely ( or never) so simple.  For example, suppose a man presents to the ED having been brought in by rescue after a car accident.  He begins to have some chest pain, and an EKG is done, which shows an Acute MI aka heart attack.  Now what was causal regarding the MI?  Was it the physiological stress of the car accident, the psychological and physical stress of the rescue transport, or perhaps his wife yelling at him before he left home?  Could the MI have occurred before the accident, and the physiological stress of the infarction have precipitated the accident?  Or, could he have bee exposed to some drug or the substance decreased his coronary flow, and been a definitive causal factor?  In this example, no one knows, and claims of such knowing are highly suspect to be thoroughly biased, and likely influenced by funds on the table.  There are simply a panoply of associated factors present, any one of which, or any combination of which, might have been causal.  The same is true with respect to medical errors, except in this field of inquiry, causal factors within the system itself are the most dominant associated factors for which individuals in the system are frequently blamed.

 

Indeed those who study medical errors fully are the first to acknowledge that prevention of such errors are for the most part systemic issues.  That is, humans are simply not error free; systems on the other hand, can come much closer by putting into place checks and balances to catch errors whenever possible.

 

In heath-care litigation, the claim made does not take into account the complexity of determining what really caused a bad outcome.  The number claimed by the Institute of Medicine was considered outrageous at the time, and for good reason; indeed this number seems high and sensationalistic.  They clearly equated bad outcome with caused by an error in care.

 

The numbers are less relevant than recognizing the presence of an underlying system problem that needs fixing.  Recently, system analysis experts have working toward a plan where the individual practitioner is not the recipient of the total blame, but a pathway to fixing the problems for all involved.

8 Malpractice Dangers in Your EHR

In the 8 Malpractice Dangers in Your EHR article, the author analyzes the legal risks implicit in the use of an electronic health record.  These include:

• The healthcare provider is legally responsible for the medical record not the vendor and/or consultant even if there is the claim of a faulty product..
• Copy and pasting text.
• Lack of password control.  Sharing your password may allow certain entries and/or additions to look like provider direct input.
• Ignoring clinical decision support without careful documentation of why.
• Customizing your electronic health record without realizing you may be affecting the main data base.  Critical pieces of data must be acknowledged not just placed in the body of the note.
• Using the meaningful use criteria for payments may lead to a change in the standard of care.
• Entering incorrect information due to time pressures.
• Altering the patient-provider interaction by focusing on the computer screen, not the patient.

It is advisable any provider should read the entire article.  Most of the time, worry about these points is unnecessary.  However, the majority of lawsuits and complaints cannot be predicted in advance.  The best solution is to fully understand that every feature an electronic health record offers has some potential downside.  If aware, the provider can compensate with some explanation placed directly in the record.

The legal field is getting more sophisticated about its analysis of the electronic health record and using it to their client's advantage.  One of the huge issues is the creation of complex meandering timeline of events.  The computer documents the exact time the data was input, but does not realize when the actual events occurred.  Spending a little time on the clinical course can put large amounts of data in a logical order.

Getting the Dread On!

My long-time Emergency department colleagues collectively called the anxiety and anticipation about having to perform perfectly on the next shift "Getting the Dread On".  This implied that the worry about the stresses of the next stint could begin any time from when the last shift ended.  The definition of dread is great fear or apprehension.  Common synonyms include fear, apprehension, trepidation, anxiety, worry concern unease, angst- you get the picture. 

After reading these descriptions, one would wonder why anybody would work at this job.  We'll save that for a another blog.

Some shift work health consequences include:

• Sleep disorders
• Diabetes Mellitus
• Headaches
• Ischemic heart disease
• Fatigue
• Stress
• Poor appetite control
• Substance abuse
• Problems with medications
• Problems with interpersonal relationships

The biggest fear is making mistakes leading to poor patient outcomes.  This coupled with volume and performance pressures, patient satisfaction scores, the ever-looming threat of malpractice suits, and chronic self-doubt can immobilize an individual.

It is probably time to retire or find a less stressful career than Emergency Medicine if getting the dread on is a recurring theme in your life.  Fortunately, most people learn to deal with the stresses and overwhelmingly positive side to the job, and they soldier on!

Who's Walking Whom (Who)?

The value of dogs as companions is well known to aid in life-long satisfaction, but not necessarily increasing the owner's longevity.  The article Pets and Longevity - Can having a pet help you live longer, the data suggests pets may not have been shown to have a direct effect on our longevity, people who rely on them for company, friendship and affection, will no doubt vouch for the impact animals have on their well-being- regardless of age.

This being stated, what do dogs bring to the relationship?

• Loyalty
• Friendship
• Physical demands- exercise by default
• No judgments

As the spouse of an animal "ENTHUSIAST", it is imperative to go with the flow and look at things positively.  The alternative leads to unnecessary conflict where you will always be the loser and "bad person".

We recently rescued a dog from a shelter that still has a euthanasia policy with 1 day left on death row.  The dog, though a handful, has added a new dynamic to the household routine.  Ricky "the dog", which came with a $10 fee has already learned our American Express card number!

Ricky is part Huskie and German Shepard and takes a walker on forced marches through the neighborhood.  The easy-walk type leash around the chest is significantly preferable for pulling dogs than a neck collars.  My upper body strength has improved since he arrived.

We have had dogs trained in the past, but trainers always train them in their vision of what a dog should behave like.  They do not train the dogs in the true reality of daily life in that household.  Absolute commandments like no sleeping in the bed and no treats are broken while the trainer is still in the driveway.  I suggest to train the dog to do the 2 or 3 things that are important to the owner.

Isolation and loneliness are common place as one ages, and pet ownership or human ownership depending on your world view will keep you younger and active.  There is a whole dog-walking culture out there ready for you to participate in.

How vital are Vital Signs?

Vital signs measures of various physiological statistics, often taken by health professional to assess the most basic body functions.  Vital signs are an essential part of a case presentation.  The act of taking vital signs normally entails recording body temperature, pulse rate or heart rate, blood pressure, and respiratory rate, but may also include other measurements.  Vital signs often vary by age.  Other signs are pulse ox or oxygenation levels, pain level, and BMI or body mass index.

Vital signs are used to determine the potential severity of illness and lead the provider to hopefully interpret the data properly to determine the most beneficial treatment plan.

Vital signs can tip the provider that patient is potentially ill when it is not clinically apparent yet.  Vital signs can also be used as an anchoring tool to deny how serious the potential illness is.

In addition, vital signs are a monitoring tool to watch if the patient is getting better or worse.  Sherlock Holmes and his modern day counterparts- the Infectious disease Consultant can reconstruct most complicated care by using the "slow" deterioration of the vital signs as critical time posts in the identification of the problem.

Vital signs need to be interpreted in the context of the situation.  They can be a clue to undiagnosed hypertension.  But a single value, the provider must follow up to see if they are consistently real.

Abnormal vital signs need to be rechecked or accounted for in the course of an evaluation.  A high percentage of malpractice cases are based on lack of documentation of the repeat vital signs prior to discharge.

As one famous ED physician once said, "Ignore the vitals and nurse's insights at your peril."  The astute clinician balances all the data in the complex rubric for medical decision making.

Adding Motivtion for Visit as part of the Chief Complaint

When writing, Dragoning aka dictating, typing and or clicking a classic history and physical exam, there is a traditional format to follow.  What may be left out is the underlying motivation or deeper concern that led to the actual visit.  Most physicians try to discern a "Reason for Visit (RFV)", and there was an academic effort not too long ago to replace the Chief Complaint (CC) with RFV, but CC is too thoroughly entrenched in the medical world.  This effort was driven by recognition that even the most common complaints - say chest pain- have underlying, relevant forces that make an individual decide to go to the ED.  Such forces can include- "MY wife made me come.", "I thought I was going to die.", or "It was about time I did something."- indicating a longer history of symptoms than might initially have been thought.  Of course, there are many, many other motivating forces of this type.

Motivation therefore includes concerns, worries, fears, family pressure, employer pressures, generalized anxieties, and specific desires.  The list goes on and n, and few are irrelevant.

Concerns about a potential serious illness like a stroke or heart attack are often very real and very present.  Eliciting early on in the encounter that the patient was worried about a stroke, for example, adds quick perspective to the evaluation.  Moreover, a very important reason for trying to elicit such concerns is that addressing them is key to patient satisfaction, and proper thoughtful care of individuals.  The patient who is too embarrassed or afraid to say anything leaves unsatisfied because their concerns were not evaluated.  Hence, it is frequently the physician's responsibility to tease these details out, as best as possible.

Another major and related dimension to motivation is the parallel issue of the real reason for the visit.  For example, we often learn that a family member "made me" and we become less interested in the family dynamics than in ascertaining all relevant key information.  This is the time to ask everyone available about what is actually going on.  How many have not seen the patient checked in with a CC of some non-specific somatic complaint- tired, weak etc., only to learn from the wife that he has had repeated exertion chest pain for weeks or months, mowing the lawn or taking out the trash.

Of course, patients often have specific agendas- medications, antibiotics, work excuses, etc. and once discerned and addressed can expedite care.  Once you actually get to the bottom line, beating around the bush ends quickly.

The benefits of asking key questions to elicit the reasons a patient decided to change his or her normal life course and come to the ED will lead to increased patient satisfaction, decreased complaints- the provider never listened to me- and reduction in liability concerns.  Cost savings are often additionally obtained because a focused evaluation solves the main problem earlier, without extensive testing or time.

When eliciting the chief complaint, try to keep the door constantly open for revealing motivation by adding sensitively phrased questions that do not challenge the patient or appear to disrespect their decision to come.  Saying- what are you doing here at 3 am with this complaint that has gone on for 6 months has the potential to put some patients and or families off.  A bit of rewording that acknowledges the human foibles in us all will help get to the bottom and provide reassurance.  Perhaps adding- help me understand what moved you or I know it must have been especially bad this time, can you tell me what was different?  This may help you to where you want to go without offending anyone.  In any case, finding out motivation for showing up will dramatically increase efficiency and accuracy.  It is perceived that the provider Listened and Cared about Me!

Acceptable Miss Rate

The acceptable miss rate is a concept that realizes even in the best of hands with all the available data accessible, there still will be some errors.  The question is whether society can tolerate without retribution aka law suits a reasonable attempt to keep this below 1% for most significant diagnoses.  The cost of achieving unobtainable perfection is rampant in our medical system, where depending the risk adverse psychology of the provider, the price tag goes from linear to exponential.

 

 

In the article The Acceptable Miss Rate, Dr. Jeffery Freeman states the typical psychology of most providers, "What are the odds that if I follow my instincts and send this patient home without any further tests that he'll seize and die, and I will spend the next five years defending my instincts as a defendant?"  The researchers among us may confer analytically on false negatives, prior probabilities, and Bayesian theory, but we all know what it means at a more visceral level.  But, in fact, most physicians do not spend cognitive energy calculating an acceptable miss rate.  Indeed, if the perceived odds re non-zero, it is quite likely that some justifiably preventative - defensive - action might be taken.

 

Medicine is a combination of art and science that rarely achieves 100% accuracy.  The provider trying to be an excellent clinician, following evidence based guidelines, and providing good follow-up care can still be sued, especially if there is a bad outcome.  Malpractice has on the one hand a financial cost, but on the other it also has a serious psychological cost.  This latter overhead is one that can have significant impact on the ability of the sued provider to continue delivering care while a case is defended.  Anticipatory prevention, then, leads to defensive medicine, and thus to unnecessary testing, more hospital admissions, and care that stays mired in process, without improving over time.

 

By establishing an acceptable miss rate protocol, it would allow physicians to use evidence based protocols with their experience to provide reasonable, inexpensive care.  These protocols could reflect reality of a 1-2% miss rate per specific diagnosis even in the best of circumstances.  The cost saving would be astronomical.  Moreover, the parallels between the practice of medicine and baseball will take one more step toward being acknowledged.  In baseball the batter aka provider steps up to the plate.  The patient aka pitcher throws him the ball.  The provider can watch it go by or take a swing- there really are no other options unless it is a wild pitch.  But in baseball, when a swing is taken, even those on a full team are allowed a certain percentage of errors.  Why not physicians, too?  We have yet to see a perfect baseball player or a perfect physician.

 



Over-Diagnosis - Ascension of the Luddites

Technology in medicine has dramatically altered the landscape of care through its ability to contribute to the diagnosis of complicated medical problems.  But as technology improves, results that containing more complex data require nuanced interpretation.  While the sensitivity of tests has increased, those tests that cast wider nets often bring specificity into question.

Luddites were 19th- century English textile artisans who protested against newly developed labor-saving machinery from 1811-1817.  During the Industrial Revolution, artisans were threatened to be replace with less-skilled, low-wage laborers, leaving them without work.  The modern day Luddites are concerned about the cost and possible harm (radiation, more tests, more surgeries) that more high-tech tests can generate.

Underneath apprehensions about over-diagnosis lies the foundational issue of controlling costs as the technology exponentially improves.  A justifiable concern is the ordering of tests when results will not alter or impact the treatment or outcome of the problem.  In a vast majority of cases, providers place such orders in the showdown of a malpractice threat that dwells just beneath the surface, subconsciously informing most every clinical interaction.

The term over-diagnosis attributes too much psychological power to the physician, who might thereby assume knowing just how much data the patient needs to know.  In my home, my wife would want to know every detail and decide for herself, rightly or wrongly, whether she's been subject to over-diagnosis or the findings represent important data.

Emergency physicians generally have a highly trained level of diagnostic accuracy.  The concept of over-diagnosis is therefore fundamentally contrary to how ED docs intuitively function, especially since emergency medicine rapidly accepts and adopts new technology into treatment guideline.  The question becomes how much technology should the provider unleash on the patient.  The Luddites lost in the 19th century and will again lose in modern times.

A problem always arises when ordering newer tests in  the first place and learning to live with the results if ordered.  This is so at least until some experience is gained.  A new name should be created to become the buzz word for the concept, perhaps--Intelligent Ordering.  Optimally, one would be judged not only on the amount of resources used, but also outcome. 

Technology is advancing rapidly.  The concern over radiation will be severely diminished with the new scanners.  Medicine has evolved realty since I began in 1975.  Back then, changes took decades to settle in.  The new time frame for gaining traction for a test is 3-5 years.  We should embrace technology, but use it judiciously.

3 Stikes and You're Out!

In 2004, the 3 strike rule was added to the Florida constitution.  In the article, Three Strikes Rule: It has been almost six years: Is there any discernible impact of its passage?, Gregory Chaires explains what a strike is.  For those not aware, a strike is defined as a final judgment by a court or agency that has been supported by clear and convincing evidence.  A strike occurs when and if there is:

1. A final order of an administrative agency following a hearing where the licensee was found to have committed medical malpractice;
2. A final judgment of a court of law entered against a licensee where the licensee was found to have committed medical malpractice in a civil court action; or
3. A decision of binding arbitration where the licensee was found to have committed medical malpractice.

The impact of the 3 strike rule is unclear with respect to its intent to "eliminate recurrent malpractice offenders".  An initial fear was that the rule would drive high-risk specialists (neurosurgeons, Ob-gyn, etc.) our of Florida.  The present data indicates that such concerns have been due to the legal definition of "clear and convincing evidence."  to establish "clear and convincing evidence" in a case, it must first be reviewed by the Florida Board of Medicine, which then decides that "preponderance of evidence" -- a less stringent standard -- has been exceeded.  Preponderance of evidence is sufficient to win a malpractice judgment, but not necessarily a strike.

Like all laws with good intentions the Devil is in the Details and the net effect is always different than believed.  The goal of getting rid of "Bad Doctors" has not happened so far, but the net effect on all the other providers has probably led to higher costs and more defensive medicine.

The fear of 3 strikes already makes a paranoid medical profession, even more anxious about malpractice and peer review.  Most physicians do not realize a referral to the Board of Medical Examiners is more high risk for their careers than a standard malpractice suit.

Hopefully, the 3 strike rule will be rewritten-- defensive medicine and higher costs will always continue to increase with the present adversarial system in place.  The New Zealand system of no-fault takes a huge step to reimburse victims of medical incidents without terrorizing providers.  After all, even in baseball, there is recognition that the batter is less than perfect.  Three strikes there too takes clear and convincing evident; you can foul all day long, but until there is a swing and a miss or one right over the plate, the batter retains his position at bat.