Posts Tagged ‘clinical care’

Primary Care Pay

Thursday, March 8th, 2012

All clinicians are aware that much of the work they perform is not billable. The gap between effort and reward is particularly acute in primary care, where some doctors may be disinclined to accept complicated new patients because it could mean uncompensated work in coordinating care.

At Brigham and Women’s and Massachusetts General Hospital, a new compensation system is being introduced to incentivize primary care physicians to accept new and complicated patients. Ten percent of a doctor’s salary will now be based on patient volume and complexity.

The leaders of the plan admit that they have yet to refine measures of complexity, but they are optimistic that this plan will help meet the growing need for primary care services.

Narrative Medicine

Wednesday, March 9th, 2011

After Rachel Adams's son was born with Down Syndrome, she became very familiar with hospitals. With attentive care, her son's health remains good. But she's noticed how doctors tend to treat the problem in front of them without considering the patient's larger story. She writes that they fix his tear ducts yet never ask how he's doing in school or how the family is coping with his treatment.

Rachel Adams is also a Professor of English. She sees an opportunity both to make her discipline more relevant and to increase the quality of patient care by infusing medical practice with humanistic values. By writing and reflecting on their patients, doctors will come to see them as characters in a larger drama. By reading novels, they will become more compassionate listeners.

Columbia already has a program in narrative medicine. It may sound like just one more task for busy clinicians to incorporate, but the theory is that reading and writing will ultimately save them time and improve patient care.

Referral Communication

Wednesday, January 26th, 2011

Any project to improve patient care will have to pay attention to how doctors communicate with each other. When I shadowed primary care physicians, I was struck by how few patients could recall exactly what medications they were taking. Since there were discrepancies between the patients' memory and the electronic medical record, the doctor had to spend considerable time updating the list and tweaking the prescriptions.

We may not be able to train patients to keep better track of their medications, but doctors can certainly control how they control vital information to each other. A new study published in the Archives of Internal Medicine analyzes data from the Health Tracking Physician Survey to test just that. They found that we still have room for improvement.

Over 63 percent of primary care physicians reported that they "always" or "most of the time" sent background information and the reason for the consultation to the specialist when they referred a patient. Specialists, on the other hand, say that only 34 percent of the time do they receive such information. The discrepancy works in the other direction, too. 80 percent of specialists say they "always" or "most of the time" alert primary care physicians of the results of the consultation, but only 62% of PCPs report receiving them.

Electronic record systems should make it easy for doctors to communicate with each other. Even where the technology is available, doctors should remember to use it.

Your First Patient

Wednesday, November 10th, 2010

We know from Mary Roach's oddly cheerful book, Stiff, that human cadavers play an unseen but important role in everything from bullet testing to automobile safety. Of course, cadavers are also central to medical education. Learning anatomy by dissecting an anonymous body is a rite of passage for future doctors.

It's also an expensive ritual. As medical imaging technology improves, some medical schools are seeking to replace live dissection with computer simulation. One school in Indiana is going in the opposite direction. They are integrating dissection into the entire curriculum by making the cadaver a doctor's first patient.

As reported in the Chronicle of Higher Education, students at Indiana University Northwest meet relatives of the deceased to gain a fuller picture of how the person lived, not just how she died. The students learn a more holistic approach to medicine, applying the lessons of their histology class to the tissues they examined.

For their part, the family members gain insight into their family's health history. The husband of one donor plans to attend the graduation of the students who dissected his wife. This approach models not only good pedagogy, but also good clinical practice.

Electronic Error

Friday, October 29th, 2010

Electronic medical records hold the promise of managing the flow of data more efficiently. When a doctor orders a test, the computerized system will automatically flag any abnormal results for follow-up.

Yet, a study at the Houston VA Medical Center showed that one-third of over 1,000 electronic alerts over a three-month period went unacknowledged. Of those cases, 45 (or 4% of all abnormal results) did not receive any follow-up at all.

In an interview with the Wall Street Journal, the study's author suggested that physicians may be suffering from information overload. Electronic medical records can send physicians up to 50 alerts and reminders each day, making it difficult to distinguish the crucial data from the less urgent.

This electronic bombardment may be exacerbated in an academic medical center, where faculty also receive regular e-mail blasts about university events and research opportunities. Some past faculty development seminars have offered tips for managing the flow of information. Based on recent response to a seminar about conducting an efficient clinical visit, we will revisit how to maximize use of electronic medical records in the spring.

Transgender Patients

Thursday, August 26th, 2010

This July Erin Vaught went to the Ball Memorial Hospital emergency room in Muncie, Indiana coughing up blood. Instead of treating her condition, the medical staff ridiculed her and taunted her because Erin is transgender.

As a result of the incident and subsequent publicity, Ball Memorial Hospital is now making lesbian, gay, bisexual, and transgender sensitivity training mandatory for its employees. The restitution also included the hospital president apologizing to Vaught.

Ball Memorial Hospital's response serves as a a model for other medical institutions. The hospital admitted wrongdoing, worked with community organizations to design a curriculum, and required training for all staff.

Of course, it's better to avoid such offensive incidents in the first place. And LGBT patients are not the only ones with particular needs. The incident shows that at Boston Medical Center, where our mission is to provide "exceptional care without exception," ongoing sensitivity training is still useful to put the slogan into action.


Friday, May 28th, 2010

Yesterday's New York Times ran a story about the rise of hospitalists in health care. The physician profiled works at the Hospital of the University of Pennsylvania, where she splits her time between patient care and information technology.

In this age of accountability and quality assurance, having a specialist just for hospitalized patients will certainly help patient outcomes and increase efficiency. Another benefit of being a hospitalist that the article does not mention is the attraction of having a predictable schedule.

On the negative side, I wonder how hospitalists can advance their careers in an academic medical center. Do they have time to reflect on their work and produce scholarship? Are they documenting the teaching they do? It's still a relatively new track in departments of medicine, so it is worth watching to see how those faculty develop professionally.

BMC Gala

Thursday, May 13th, 2010

Over the weekend I attended theĀ Boston Medical Center gala. In many ways, it was a typical fundraising dinner. A local newscaster emceed, the mayor of Boston spoke, and we ate wan chicken entrees.

What made the event memorable and even emotional, though, was a video montage of patient stories. Screens throughout the hall showed three BMC patients with complicated illnessesĀ and how their doctors helped them overcome problems. Then, the lights went back on and the patients came on stage to a standing ovation.

As moved as I was by the skill and compassion of the BMC physicians, I couldn't help but notice that all the cases involved surgeons. Certainly, removing a tumor provides dramatic before and after images, but what about the medical interventions? Where are the heroes of the Department of Medicine who demonstrate BMC's mission of "exceptional care without exception?"

Doctor-Patient Interactions

Wednesday, May 5th, 2010

On the second day of Dan O'Connell's visit, he addressed a lunchtime group of clinicians on how to communicate more effectively with patients. Although I am not a medical doctor, I took away some key points that can make interactions with any client go more smoothly.

He emphasized that the doctor and staff must work as a team. The worst thing a doctor can say upon meeting a patient is, "What brings you in today?" The patient has already shared his or her concerns with the medical assistant and usually the referring physician, so an opening statement like that signals that the group is not working together.

A little preparation--even a five minute huddle with staff before clinic--can go a long way in smoothing out the day. This is advice that translates to many settings.

Patient Care

Friday, April 16th, 2010

In yesterday's faculty meeting, members of the Department of Medicine discussed a proposal for improving hospital care. In just the few days I have been a part of the department, the attention the faculty pay to patient outcomes is apparent.

My training is as a social scientist, not a health provider, but illness is often a cultural construct as well as a physical one. Journalist Anne Fadiman describes a dramatic example of this in her book, The Spirit Catches You and You Fall Down.

In the tale of a Hmong family interacting with the western medical system, she suggests that much confusion and pain could have been avoided if doctors had taken the Hmong belief system into account. Medical anthropologist Arthur Kleinman suggests a simple way for physicians to see illness through the patients' eyes.