About WingofZock

Physician

The Degradation of Medicine

It’s becoming increasingly difficult to practice the type and quality of medicine that we medical professionals have cherished throughout our careers!!!!  The professionalism and the expected standards of care have been systematically and insidiously degraded over the last decade.

It began with the use of the Libby Zion case to rally around fatigue as a cause of medical errors and has evolved into the complete transition of the medical profession to a shift-work, employment based model!!!

At first the powers-that-be, namely the ACGME who governs all things regarding Medical Resident Training, began to use ‘fatigue’ as the reason to restrict work hours, including total hours worked.  This has become increasingly restricted to not only include short work shifts, but days off for personal time, days off for rest, time away from the patient for various non-clinical obligations and amazing restrictions on patient numbers.

In effect, a houseofficer can essentially work 12 hours, take care of 5-7 patients in that time, must leave the building and their patient at the end of their work shift and completely lose the ability to observe and care for his/her patient during the most critical and educational time in the hospital, the first 36 hours.  In essence, medicine has been transformed into a shift-work, employment based occupation where continuity, doctor-patient relationship and strong sense of ownership of a patient’s care have been all but eradicated.

There is also a strong push to separate inpatient and outpatient training and make the mutually exclusive.  This will, and I believe it is by intention, further degrade the doctor-patient relationship.  Already it is difficult to get a primary physician to evaluate, treat and engage his patient when he is needed most….when the patient is seriously ill enough to require hospitalization.  This will be eliminated at it’s origin….at the time of training.  The physician who cares for his patient when both well and ill will cease to exist, as will any form of relationship and continuity.

Currently, the most caring and capable physicians are those that care for their patient’s when both well, when sick, and back to being well again…..this will be a thing of the past by design.  Sadly….

The current training process will eliminate the ability for a physician to be everything to his patient, care will remain fragmented, communication sloppy, relationships weak and care poor.

As it is i’m repeatedly faced with arriving for rounds, there is no information available from the prior housestaff work shift and the explanation for various occurances repeatedly is ‘I have no idea, they didn’t tell me anything about what happened’…..the saddest thing is that no one seems to think this is a problem.   Hey, it wasn’t my shift!!!!  Yes….and they don’t feel like it’s their patient either….just another number to deal with during their 12 hours on the way to the day off!!!!!

God I hope I don’t get sick!!!!

And more about marketing….

It’s frustrating that hospitals and administrators have become increasingly involved in the delivery of medical care by physicians in an attempt to manipulate the institution’s public statistics.  It’s also frustrating that this approach is being driven by the ‘so-called’ groups that advocate quality.  Where groups such as the JCAHO, Institute of Medicine and the States that publish ‘Quality Measures’ purport to aim to improve quality, all they do is cause the degradation of quality medicine by forcing physicians and hospitals to focus on ensuring the ‘data looks good’.  Published Data about hitting targets for treatment of certain medical conditions (DVT prophylaxis rates, Health Care Associated Infection Rates, Influenza Vaccination rates, etc) do nothing to indicate whether a Physician is a good one, whether they can actually make a diagnosis and treat a patient at a high level.  Now, individuals who make sure that the ‘data’ looks good will be considered the ‘good ones’ even if they couldn’t take care of my dog.

Hospitals have become expert at manipulating Ventilator Pneumonia rates, Line infection rates, Mortality, etc.  Did you know that in many hospitals in NY, NJ and PA there have been ZERO Ventilator Associated Pneumonias in the last 5 years…..and despite this there have been quite a few!!!!

The quality measure that tracks the ‘Time from Admission Decision’ in the ER to transfer out of the ER has led to patients being diagnosed and admitted with ‘bridging orders’ even though the diagnosis isn’t close and the bridging orders merely say ‘admit to floor’ with no diagnostic or treatment orders…..but, although the patient will languish on the medical floor awaiting real orders and a real diagnosis….the quality is excellent because the patient made it out of the ER in less than 90 minutes.  Gotta love the priorities!!!!!

Then there is the push for the almighty Electronic Medical Record (EMR) and Computerized Physician Order Entry (CPOE), which are also supposed to improve quality.  How, I’m not so sure, but it’s supposed to.  Now we have Emergency Physicians sitting at computers typing instead of at the bedside diagnosing and treating.  Next up…..the same in the ICU’s…..which will lead to very cursory discussions of patient issues and treatment plans because it takes forever to type it all out.  Now what you’ll see is just a list of problems without any discussion of the issues and plans.  So much for quality through improved communication and discussion.

I recently received a note from the Electronic Record of a Cardiologist at the University of Pennsylvania, a quality institution.  The note included list of Assessment diagnoses and a list of Plans,  all generated by clicking off the correct boxes, and not a thing was discussed about what the clinician thought and why…..I have no idea what he thought.  I already knew the list of diagnoses but wanted to know what his thoughts…..and nothing!!!!  So much for the record being a place to discuss your thoughts and plans in a detailed fashion.  I will say, it was a perfect note….had all the components and Systems Review to receive the highest level of coding and billing!!!!

As for order entry….in an attempt to create uniformity, it has become impossible to individualize treatment on a daily or minute to minute basis, unless you want to jump through major hoops to do so.  And when you have 30 patients to see, who is going to sit and spent 20 minutes typing orders when the hand written version would have taken 3 minutes……and would have been more to the point and detailed what you actually wanted to have happen.  Ahhhhh….cook book medicine (or should I say ‘evidence based medicine’).  I do understand the intent….now you don’t have to be smart and well trained, or experienced and talented, to practice medicine….all you have to do is click the right boxes and we’ll all look the same!!!!

Now, I’m all for Evidence Based Medicine, in fact I’ve been practicing that way since before it became in vogue, it’s just how I was trained at the U of P…but….no two patients are the same.  And therefore, no two treatment plans should be same, not even close!!!!  Too bad, but now you merely have to click the ‘Pneumonia order set’!!!!!

Well, that’s my rant for today!!!

 

 

It’s all about marketing…

It’s just a shame that medicine and healthcare has come down to what ‘looks good’ in the reports and statistics but requires abandonment of what’s best and most ethical for the patient.  I have a patient in my ICU who recently underwent a cardiac surgical procedure but has been very slow to recover after a myriad of complications.  He didn’t really want to undergo the procedure but agreed after pressure from family.  He’s been slowly recovering but recently was set back by some kidney and respiratory issues.  He is fully awake, aware and capable of deciding his treatment and has begun refusing certain treatments.  Unfortunately, the cardiac surgical team has been fixated on the 30 day mortality target to get the patient ‘off the books’ after a discharge to a lower level of care.  And they’ll do anything to get there.  This poor man has been asking to be left alone and allowed to die in peace if that’s what happens and has been ignored.  He’s been placed on a respirator against his wishes, has had procedures against his wishes and been treated for kidney failure against his wishes.  Nursing and other staff that wish to advocate for the patient have been told to go away and mind their own business and family have failed to step in.

It’s really a shame.  The first ethical principle of patient self determination and their right to govern what happens to their own body has been completely abandoned by those whose primary interest is self-promotion through good outcome statistics.  All that seems to matter these days are mortality statistics and complication rates with no interest in how these outcomes were achieved, and at what cost to the poor patient.  And I’ve seen this repeatedly….every time there is a complicated case or poor outcome the goal becomes the 30 day survival time frame and discharge to an appropriate level of care for the DATA, not the patient.   In addition, the patient is kept in a critical care environment to ensure the outcome at the added cost, added risk of secondary infection and delayed rehabilitation.  Then comes the transfer directly to a nursing facility with minimal skilled nursing care after the patient was supposedly too sick to transition to a lower lever of in-hospital care.  And we want to know why healthcare is so expensive.

Sadly, so much emphasis has been made of these ridiculous outcome statistics that surgeons will pick only cases that make them look good to the exclusion of those more complicated and need the treatment.  Then god forbid there is an irreversible complication, the patient is tormented until they can come off the surgeon’s ‘books’.

Unfortunately, we all know who these physicians are.  I just don’t understand why the ‘system’ doesn’t care and move to eliminate these types of behaviors????  I can’t imagine it’s that difficult……

‘Tis the season….

It’s that time of year…..the time of the Mom and Pop – Drops!!!!  You know, when the family with big holiday plans doesn’t want to care for their elderly Mom or Pop.  So where do they end up, the ER to be evaluated for ‘not looking good’ or ‘back pain present but unchanged for months’, expecting a hospital admission for an evaluation.  Of course, when you tell them that there is no acute reason for admission they become angry saying ‘they can’t care for them’ and refuse to take them home.  Hense, in they come….on our dime!!!  And we want to know why Medicare is bankrupt?  To make it worse, it turns out there won’t be anyone around to receive the patient home or care for them until after the holiday, and of course, they refuse placement into a longer care nursing facility.

The fact that there is no recourse is just another example of how the system is broken.  The attitude on the part of many families, that this is an acceptable use of the system, is just another example of entitlement.

I remember staffing the VA Medical Center ER during winter holidays.  Poor veterans would be sent by taxi and left at the ER ambulance bay with suitcase in hand.  When their evaluation was completed and they were deemed able to be discharged home, we’d either get no response from the family, or worse, they’d tell us that there would be no one home and that the door would be LOCKED if we sent the patient home by cab. Welcome to the VA Medical Center for the holidays!!  So very sad…….!!!

There is so much wrong with this picture!!!  From the government allowing this to occur with zero repercussion or cost to the patient or family, to the attitude of the family toward their loved ones, to the system’s inability to facilitate the return of the patient to their home.

In reality, if there was any cost to the patient or their family, these issues would cease immediately.  Unfortunately that is deemed unacceptable by those in charge of the system.  The problem will just continue to become worse until there is some accountability and sense of responsibility instilled into the system.  Sadly, this is also a societal problem, further illustrating the sense of entitlement pervasive in our society today.  No wonder the healthcare system is broken and bankrupt.  And, there seems to be little resolve to fix it!!!

Welcome to Medical Madness

And so we begin…..so much to say.  Ridiculous things happen in our healthcare system every day….I’ve no idea where to start.  But, since healthcare is a complete disaster these days, I’m sure there will be much to discuss and comment on.  We’re looking forward to hearing what everyone has to say!

They would roll over in their graves if they only knew…….