Monday, December 28, 2015

Preserving the Mental and Physical Health of the “Graveyard Workers”

In the article 8 Ways Working the Night Shift Hurts Your Health, authors suggest that working night shifts can lead to 
  • Sleep disorders
  • Increased diabetes risk
  • Increased obesity risk
  • Increased breast cancer risk
  • Altered metabolic state
  • increased risk of heart attack
  • Increased workplace injuries
  • Depression.
Any medical provider can add to the list:
  1. Anxiety
  2. Drug Abuse
  3. Alcohol abuse
  4. Marital discord
  5. Family stresses
  6. Increased Errors
  7. Career dissatisfaction
  8. Burnout
  9. Vicious cycle of sleep/circadian disturbance
  10. Impaired judgment
  11. Etc., etc., etc. (Add your own) 
In industry, most major mistakes happen between 2-4 AM. This occurs even with workers who exclusively work nights on a consistent basis.  Yet, most medical practitioners work night shifts intermittently, and the on-again/off-again cycle of this scheduling dramatically alters circadian rhythms. As a provider gets older, especially after passing the age of 50, these issues get more pronounced, more difficult, and sometimes worsen to an extent that make them very visible to others.
What’s a person to do who has chosen the EM lifestyle without foreseeing all its potential consequences?  An article in web MD gives some steps on avoiding work sleep disorder.  It is titled Could you have shift work sleep disorder? It can be found at: ( )
The underlying purpose of this blog on the topic of night shifts is to remind everyone to “LOVE” and “CHERISH” any body (yours!) willing to work night shifts. Doing so is not easy. It can be especially difficult for those of a hardened EM mindset, who not uncommonly beat their bodies into submission, just to accomplish the work.  Most of us have been there at one time or another.
Just as it is hard to quantify the dangers of ignoring one’s own mental and physical health needs, so it is equally difficult to quantify the other side of that fence: the important psychosocial benefits of self-care. Ignoring reminders we get in this area comes at a considerable price.  Being an ostrich, in this turf, has deep ramifications.   The winds still blow over the plain when the ostrich head is below it, but its body is still exposed. Costs come in terms of physical health, mental health (paranoia), social isolation, and difficulty fitting in with the rest of society (populated by other birds that have a “normal” work flow).
For those who have reached elder status, continue to work, and have sweats and shakes if a night shift is scheduled, those who are willing (or sometimes coerced) to do nights-only are precious commodities.  How do you keep them alive, happy (or at least not miserable), and preserve the benefit they give? Most importantly, reimburse them well with shift differentials, RVU’s, control of their own schedules, psychological support, and ears that remember to “listen to them”.
Don’t underestimate the need to pay attention to them. They are usually working in an environment that is fundamentally different to the day shift. Their concerns might not be appreciated and/or respected. And sometimes just listening has great benefits, even when no action is taken, or can be taken.

Monday, December 21, 2015

Malpractice Worries Enter a New Level of Sophistication and Complexity

Malpractice claims are usually rooted in poor communication, failure to diagnose, bad outcomes, and poor interpersonal relationships. This has been exacerbated by the Electronic Health Record, increasing sophistication of the lawyers, and an antiquated malpractice system that assigns personal blame to the provider creating an acute-on-chronic adversarial relationship. The doctor/provider-patient relationship is supposed to act in harmony to provide physical and psychological care to the ill.
10 New Malpractice Concerns, and How to Avoid Them article is a highly recommended read for anyone practicing in high-risk fields.
The author suggests that there are 10 new risks in addition to the usual suspects.

1.       High deductible insurance plans (de facto self-pay) are forcing patients to eschew their treatments or follow-ups. They recommend you document the potential seriousness of the problem.

2.       Following clinical practice guidelines that are not necessarily the standard of care in the community to save money. The standard of care is established by the specific jury of an individual case.

3.       Accountable Care Organizations (formally known as HMO’s) function on the basis of providing coordinated care while spending less resources. This does not matter to the individual patient who feels they have a bad outcome due to organizational/rationing of their care.

4.       Team Care which means the physician, nurse practitioner, physician assistant, nurse, social worker and etc. working together with no obvious leader in charge. Make sure everyone knows their level of responsibility.

5.       Having Smart Phones distract you. Patients usually mistrust providers who take non-emergent phone calls during a visit. This also includes having your back to the patient typing on the Electronic Health Record with no eye contact.

6.       Social Media should be avoided.

7.       The Electronic Health Record has a slew of potential problems. These have been elucidated in previous blogs endlessly. The biggest problems are 1. Cut and Paste Macros 2. Inadvertently clicking on data points that really have not been performed. 3. CPOE issues 4. Ignoring alerts 5.Not realizing that metadata is being collected that states when, where, and which computer the documentation occurred. 6. Time stamp issues 7. System errors with lack of training and systems not specifically designed for certain locations. 8. Lack of easy access to the nursing notes. 9. You may be obligated to know the entire past medical history including pharmacy because it is potentially available 9. ETC.

8.       Telemedicine has been predicted to be 5 years away from serious litigation. This includes liability and breaking state Board of Medicine rules. Every state has different rules and your malpractice coverage may not cover you for Board of Medicine complaints.

9.       Employed physicians are at the potential mercy of their employers. One may not have a say in the legal defense or the battle plan.

10.   Complaints to state boards can be worse than malpractice. You are usually guilty till proved innocent and have to pay your legal costs. Some states like Florida have 3 strike rules where a complaint the Department of Professional Regulation counts as a strike. This can be life-disrupting. 

In conclusion the best way to stay out of trouble is good communication and GOOD LUCK!

Monday, December 14, 2015

Can Defensive Medicine Decrease Lawsuits?

The authors of Physician spending and subsequent risk of malpractice claims: observational study try to determine whether increased clinical use of diagnostic resources serves to decrease malpractice claims. While they were able to show an association between greater physician spending and reduced risk of malpractice claims, they were unable to determine an underlying cause for increased resource use.
That is, the reason (cause) for this association is not entirely clear.  We can speculate, of course, but it is wise to remember that doing is simply that, speculation.  
Consider two possible causative explanations, one employing a defensive approach, and the other an offensive approach.  Opposite forces, same result. How?  In the first, physicians studied may actually have practiced defensive medicine, with the mindset of defending themselves from lawsuits. In the second, they have practiced offensive medicine, being more careful for the benefit of their patients, and being little influenced by defensiveness.   In either case the same association would have been shown: more tests, less suits.  Indeed, it could be the case that more careful doctors make more accurate diagnoses, and have fewer suits.  The only difference between these obverse sides (defensive/offensive) is motive.

From the defensive side, the authors give multiple reasons why malpractice occurs where some skill improvements might be of benefit, including poor interpersonal relationships and impaired communication abilities.  From the offensive side, when one is doing one’s best in behalf of a patient, there is little that can be done about unanticipated bad outcomes, unexpected diagnostic errors, cognitive errors, and systems errors. These happen to the best of us.

Nevertheless, defensive medicine is a fact of life for most physicians in the United States. It is present to some degree, even if slight, in most of us. It is the “Elephant in the Room.” Even though multiple studies contend that malpractice risk is overrated, those of us who have practiced for more than a few decades (or more) know that a multiplicity of factors get poured into each clinical decision, and no less into the question of what tests to run. While defensiveness may creep in now and then to some degree, it is not the whole picture, as it simply does not control clinician minds. Most of us make decisions based upon that we think will benefit the patient, not upon what will keep us out of court.  True, a good outcome is less likely to result in a suit, but we tend not to live in a pessimistic world where every patient is a lawsuit waiting to happen. Some believe that physicians do think that way, but it is an untrue picture because most practice optimistically.

Yes, there are those who have allowed defensiveness to rise to the top in their decision-making.  But not all in the house of medicine have done so.  No, not all, and more precisely, only few have defensiveness dominate.   Of course, for each of us, there have been times it has become more of a force than we would like, perhaps when under stress, or perhaps when the memory of encountering a plaintiff’s attorney is still fresh. But for the most part, we get back to practicing primarily for the sake of patients, letting potential litigation chips fall where they may. We do that largely because we know that lawsuit apprehension is not what really motivates us, nor what is best for our patients.

Unfortunately, a big part of the malpractice setting is the psychological and emotional damage a suit inflicts on defendants. Loss of money may happen; worse are losses of self-esteem, meaning, and identity. Then there are the potential appearances of alcohol abuse, substance abuse, and marital discord. These are only a few of the untoward consequences that accompany becoming a malpractice defendant.  There is also the chances one may lose their job or that potential advancement may be spoiled. The state of Florida has a 3-strike law that can actually force one to leave the state. We have been told that being referred to the State Department of Regulation can be a worse experience than being sued.

A provider who is currently, or was previously, a defendant must live with a cloud that follows him or her around, raining thoughts about the “mistake” that may have harmed someone. Whether fault really was present is often irrelevant when the defendant bears psychological consequence. Endless pressure to perform at 100% accuracy in a world where errors are not taken lightly, may, over time, extract a toll on the joy and satisfaction practicing medicine should otherwise have. One sometimes hears youths, as well as mature ones, say that medicine can be a great career, but there are easier ways to make money.

It is important to be cautious and, as we have noted, caution can lead to greater expenditure and resource utilization.  But, as we have noted, cautiousness may be directed not only toward oneself (defensively, by the ordering physician), but also toward the patient (offensively, to be sure nothing important is missed).  Now, when we, or one of our loved ones, becomes sick, don’t we want the cautious, caring physician, on the offensive in your corner, whether his ordering stats appear to be “defensive” or not?

Are there any solutions to this conundrum? Having a non-combative no-fault malpractice system (as in Australia) would be a good start. While a no-fault approach does not eliminate malpractice claims, it enables most injured patients to get their day in court without demonizing the provider.

Communication and system issues are prime sources of patient dissatisfaction. Still, because little can be done to reverse a bad outcome, a no-fault system has definite advantages.  It has the ability to provide resources for the patient and the family, while simultaneously protecting all concerned, including the physician.

In conclusion, it is only logical that providers might order more tests to protect themselves from all the downsides of lawsuits.  On the other hand, it is also only logical that physicians order tests in larger numbers to protect their patients from bad outcomes.  How do you tell these apart? These two paths to more testing are indistinguishable.  But in either case, even though the provider is being risk averse for two apparently different reasons, ordering more tests will not prevent lawsuits.

Monday, December 7, 2015

The Unintended Consequences of Good Intentions!

Another guest blog from Dr. Donald Kamens on the health-care exchanges- a personal experience.

Sometimes the symptoms of a disorder are the best clues about etiology.  In the case of healthcare insurance 2016, we have a disorder that is a horse, but not a zebra.  Why? Some would have you believe that rising costs are secondary to the high cost of emergency room care (zebra, or baloney, whichever seems more appropriate).  However, any individual not provided insurance by an employer, can try to buy coverage independently (or for a family member). Thereupon, the horse comes out of the barn.
So what is the breed of that horse?  Is it a Quarter-horse, an Andalusia, an Arabian?  No indeed.  That horse, is a Complexity-horse.  A tough breed, difficult to train. In fact the complexity here is so intense, that a new specialty has arisen:  the CAC (Certified Application Counselor).  Why?  Because applying for coverage is so complex that guidance, or counseling, is needed.  Well, it does not take a rocket scientist to figure out that if a system requires that it spend money for advisors to help hold the hands of applicants, something deeply internal is wrong.  The complexity is just too costly, in and of itself, regardless of the costs of care! What a conundrum!

Now, here’s a live example.  I have been trying to buy healthcare insurance for my wife. She left a teaching position several years ago to pursue other dreams, and that meant finding our own insurance plan.  In November 2016, that is so complex that the neighbors, many miles away, may well hear me screaming.  My years of working in this milieu, as a physician, as an administrator, and as a group principal, do not impact the sense of swimming through spaghetti.  Here are just some of the issues I ran into:

1.     The “marketplace” is impossible to discern.  Every state has its own pallet of availabilities, and within those, each company there is a bewildering spectrum of plans.  The website pages are impossible to read.  Even with page expansion on 36 inch screens, my wife even took pictures of me pouring over them with a magnifying reader.

2.     There is a proliferation of acronyms, incomprehensible terms, and head-scratcher delineations.  IF (and that is a big IF) one gets to see them, one has to do considerable deciphering.  DED means deductible; yes.  But then, you have to figure out and research many (many) others (e.g. PCY  ...per calendar year.  Something wrong with /yr.?). There are tons more.  And then, do you know what $1/$5/$15 means?  In some places (but not all) it means tier 1/tier 2/tier 3 drug costs. 

3.     The plan listings are in disorder.  For one company I was examining, there are bronze, silver, and gold plans. Fine, the idea is clear that gold is best, and so on.  But not so fast.  In this one, they are listed with bronze at the top, gold in the middle (though the costliest), and silver at the bottom being the only one with no drug deductible. What?

4.     The websites do not work very well.   Not uncommonly one gets bounced and has to start over, or some button does not work. Or worse, as on one site, things start acting crazy.  Here, it asked me the number applying for coverage [=1]. Then the number of people living under the same roof, including those not applying for coverage [=3]. Then it said “Sorry the number in your household does not correspond with the application number.” Seriously. Really.

5.     This is a mess!  Did I say that before?  The intentions of those who have set such things up, we have to believe, were good, even if modified by legitimate business concerns.  However, the outcome of this complexity is going to shoot the whole system in the foot. Or the head.
Worse than being a mess in just one state, think about setting up all these complex plans for 50 states! It has been no easy task. Nor was it free.  How much chemotherapy for a patient who could not afford treatment could this baloney have paid for?  I would estimate that if the amount spent on the complexity of the system were actually put into delivery of healthcare itself, the benefits to people would be immense.  This insurance mechanism is a waste of money, a waste of time.  And the real benefits to people are, I would venture to say, going to cause more problems than anyone needs.

Finally, here is my suggestion for an insurance application having five parts:

1.       Do I need health care coverage?  [  ] yes   [  ] no

2.       What is my income:  _____________

3.       How much can I afford per month per individual or per family for coverage?

[  ] $0 [  ] $10 [  ] $50 [  ] $100 [  ] $200 [  ] $500 [  ] $800 [  ] $_______

4.       Do I have any known illnesses requiring care? [list] _______________

5.       When do I want it to start? ____________________

In the past, when colleagues said they were leaving medicine because it was becoming more and more difficult to practice, I tended to think “wimp!”  Now I am myself thinking of leaving the country and finding a more rational solution to just being a citizen who might, or whose family might, need care someday.