It’s a frightening statistic—400,000 patients die every year due to preventable, medical errors. This was the topic of testimony in the Subcommittee of the US Senate Committee on Health, Education, Labor and Pensions hearing, “More than 1000 Preventable Deaths a Day is too Many: The Need to Improve Patient Safety,” on July 17, 2014.

National patient safety experts testified before the subcommittee urging lawmakers to focus attention on patient safety and the need to track and reduce medical harm to patients.

The recent study by John James, PhD, a scientist and advocate whose son died due to medical errors, reports these alarming statistics. Dr. James asked lawmakers to establish a National Safety Board to investigate patient harm and suggested a standardized patient bill of rights.

Peter Pronovost, MD, PhD, senior vice president for patient safety and quality at Johns Hopkins Medicine and Ashish Jha, MD, MPH, a professor at the Harvard School of Public Health, called for the Centers for Disease Control and Prevention to track medical errors since they already collect data on hospital-acquired infections.

Tejal Ghandi, MD, MPH, president of the National Patient Safety Foundation, said that medication errors occur in up to 25 percent of patients. Ghandi also explained that diagnostic errors are also part of the problem, contributing to the number of fatal medical errors. She called for systems to be put in place to monitor patient care.

Lisa McGiffert, director of Consumers Union Safe Patient Project, asked legislators to create more meaningful public reporting of medical errors so the the general public would be more informed.

Part of the problem, experts agreed, is the need to develop measurements of patient safety efforts to produce credible data.  

Preventable, patient harm is the third leading cause of death in America, trailing behind heart disease and cancer. Let’s hope this hearing is one of many major steps toward transparency and reduction of preventable, medical errors. Medical processionals, medical facilities, patients and their families, must work together to increase patient safety for patients.

Patient safety is a team effort.

To view the Subcommittee Hearing see link here 

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The new, award-winning documentary, Code Black, directed by emergency department physician Ryan McGarry, MD, reveals an insider’s view of the dynamic young doctors and nurses who struggle to save lives in an overburdened healthcare system at Los Angeles County-USC Hospital, one of the busiest emergency departments in the country.

The old L.A. County emergency department, “C-Booth,” considered the training ground for emergency medicine, is the initial focal point of the film. C-Booth captures the inspiring and the grisly of medicine in one of America’s first trauma bays. The film zeroes in on doctors and nurses crammed together in the trauma unit, shoulder to shoulder, treating patients with life-threatening situations. These scenes are vivid and alive, albeit gruesome.

The passion and commitment of these medical professionals to do whatever it takes to treat all patients is inspiring. Watching it revitalized my hope about healthcare by shining a light on what truly drives medical providers to enter the profession in the first place. This is the heart of trauma medicine in C-Booth before paperwork, data entry, checklists, HIPAA, and more, enters the provider-patient relationship.  

Flash forward to the site of the new hospital which was rebuilt in 2008. Gone are the cramped quarters with blood stains on the OR floor. For all the new elegance and flow that has replaced the frenetic energy of C-Booth, a distinct and prominent separateness between providers and between providers and patients has settled in. The new hospital allows for current requirements, digital documentation and protocols which C-Booth couldn’t accommodate. 

In a fascinating Q&A after the movie with Ryan McGarry, MD, and Jamie Eng, MD, McGarry explained to our audience that with the new requirements only 1/6 of their time is now spent seeing patients and the rest is relegated toward documentation and digital paperwork.

If doctors only have 10 minutes per patient in the ED and the rest of their time is spent entering information into computer databases, where does that leave the doctor and the patient? This is the vital question posed by Code Black. Even with the Affordable Care Act (Obamacare) there are still as many patients in the ED, if not more. 

The sticking point, however, is that patients need privacy, patient safety checklists, protocols and documentation for quality and continuity of care. If entering billing codes, filling out forms and further data entry widens the chasm between providers and patients, what do we do about it?

This excessive digital documentation is eroding physician satisfaction. In a Forbes interview, Malcolm Gladwell said, “It’s this side of medical practice that wears down even the best physicians.” And that can certainly translate to patient care.

Paperwork or documentation takes up a third of a doctor’s day, particularly with residents who must make clinical decisions with less face-to-face time with patients. With the onset of electronic medical records, this problem has eased only to yield another. “Residents may rely on notes written by other doctors instead of talking to the patients themselves,” Pauline Chen, MD, wrote in her New York Times article, Doctors and Patients, Lost in Paperwork.

There’s no easy solution to reduce the amount of documentation, staff shortages, financial cutbacks and more in hospitals like L.A. County-USC Hospital (and others,) but in Code Black, McGarry and the medical team devise a new approach by initiating care for patients in the waiting room instead of triaging cases simply based on computer data. The doctors and nurses realize that relying on code doesn’t allow them to evaluate patients face-to-face and leaves many suffering miserably in the waiting room, often for 10-18 hours at a time. 

Compassion for patients is what drives this team of medical professionals to put their heads together and come up with a strategy to overcome some of the barriers.

Code Black addresses the very pertinent issue of the provider-patient relationship and the challenges that threaten it. I hope everyone will see it. You don’t have to be involved in healthcare to enjoy it and to be moved by it. It’s a fascinating and dynamic documentary that reveals the heart of medicine and its current obstacles.

 

 

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Taking charge of your healthcare means taking charge of yourself as a patient and meeting the medical provider half way.  Studies show that if patients are actively involved in care and partner with providers, that they experience better health outcomes and lower costs. See Health Affairs policy brief here.   

But for patients to be active participants in care they must be willing to acquire knowledge about their diagnoses and treatment plans and learn how to navigate our complex healthcare system. This requires motivation to do basic research, to keep track of symptoms and share those symptoms with providers, to understand basic medical information, to ask questions and partner with medical providers in shared decision-making, and to take ownership of medical information.

For patients with serious illnesses and conditions, this can be a part time job. I’ve been there. I had a serious, chronic pain condition for 16 months, and towards the end of it, seeking solutions to my pain took all the energy I had. 

According to the recent WSJ article, The Health-Care Industry is Pushing Patients to Help Themselves, patients are now encouraged to engage in care, to keep track of their medical data, to seek preventive care, and to manage their conditions.

The Institute of Medicine report, Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement, highly recommends that patients participate in care and states that the onus is on clinicians to activate patients. There are incentives for providers who show “meaningful use” of technology, including engaging patients and families in decision-making and providing them with their health records and clinical summaries.

Is this realistic to expect clinicians, who are already short on time and dealing with patient overload, to take on the responsibility to educate patients on patient engagement?

With both of my books, The Take-Charge Patient and Critical Conditions, I encourage patients and families to take active roles in care, and illustrate how to prepare for medical appointments, gather copies of pertinent medical records, create symptom diaries, ask questions and do research, create medical histories, and to form partnerships with their providers to share decision-making.

But the information requires patients to take on new roles and attitudes regarding their healthcare and their providers. This can be particularly difficult for some who are from different cultures and might be unfamiliar with the notion of collaborative relationships with physicians.

What about older seniors with multiple medical conditions and cognitive decline who are simply unable to engage in care? They need advocates. We need educational courses or seminars for their advocates and other caregivers. There are many of these seminars, thank goodness, but there must be a way to standardize the information and to reach all people.

I don’t believe that medical providers can shoulder the responsibility of giving patients and their families/caregivers a college course in navigating our healthcare system and how to advocate for themselves or others. There is a movement to reach patients directly, not only educating them on patient engagement but  empowering  them with information. My fellow advocates and I are part of that movement. The National Patient Safety Foundation states that most U.S. patients are relatively uninformed and are still passive recipients of heath care services who lack the confidence and skills necessary to engage as proactive patients. If that’s true, then we need to expand and deepen the outreach.

Patients need step-by-step directions at the ground level in their primary language, as do their advocates/caregivers. We can focus on health policy change, focus on meaningful use through providers, education and information tools through providers and advocacy organizations, which is absolutely necessary. But until patients are educated directly by an outside source, in addition to what providers offer, we’re looking at some possible long-term challenges.

There is still too much of a power imbalance between patients and physicians for information on patient engagement to be received in ways patients can adequately put to use. Patients can be intimidated by providers and some worry about creating conflict that could affect their care. How can patients integrate information provided by their physicians and nurses at a time when they are being seen for illnesses and conditions? I know I can’t. 

For example, take a sixty-five year-old man who sees his doctor, having put off a visit because he dislikes seeing doctors, and hasn’t seen one in a couple of years. He’s had abdominal pain for a few weeks and isn’t feeling well, maybe even anxious in the doctor’s office. At the time he’s given a diagnosis and possible treatment plan, he is also being educated on how he can be an active participant in his healthcare, including how to access his medical records, how to partner with his physician, and more. All this person probably wants at that moment is to feel better. But he’s being coached on patient engagement at the same time he’s being evaluated.

Patients should be educated about their role in care at a time when they are not seeing providers for diagnoses and treatment plans. This information should be presented in required courses in high schools and colleges, through government sponsored seminars in a variety of modes so everyone has access to the information. Not everyone is internet savvy. The information should be taught via live seminars to those who need it most, including people in low-income and rural populations and those who have recently gained access to healthcare.

At the very least, why can’t hospitals and healthcare organizations send out ambassadors of health, for lack of a better term, to local community groups, to offer free seminars to the patient population? This would not only provide education in a comfortable environment for patients and families, but could potentially expand their customer base.

I feel this is an urgent, unmet need the system must address. Everyone, on all sides of the table, is doing their best to change how healthcare is delivered and received. If standardized patient education were available to the masses, the goal of increased empowerment and engagement would be in reach. 

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You might not think of calling your pharmacist if you have a medication question or minor medical problem. Your pharmacist can offer advice on prescription and over-the-counter medications and many offer treatment of minor injuries and ailments, prevention and wellness services, immunizations, and more.

Pharmacists’ roles are now expanding from drug dispensers to drug educators and chronic disease coaches, according to the Kaiser Health News article, Pharmacists Expand Role to Help Educate and Coach Patients

The U.S. Surgeon General recently released a report that demonstrated the value of healthcare services directed by pharmacists.

Here’s how my pharmacist helped me.

It was 5:30pm on Wednesday. I’d placed a gel ice pack on the side of my knee to treat pain that resulted from an annoying, awkward twist in a Zumba class I’d tried for the first time. The knee pain was minor, was improving, but I decided to ice it in hopes that I could get back to my regular hip-hop dance class the following morning. I made the mistake of placing the gel ice pack directly on the skin. Within 7-10 minutes my knee looked as though it had been scalded with boiling water. The skin was puffed up, angry and a deep shade of pink, with a red, fuzzy line surrounding the six-inch square. It felt hot to the touch. 

Since my primary care physician’s (PCP) office was closed, I called Arian Moini, a pharmacist I’d known for many years and whom I interviewed for my latest book, The Take-Charge Patient. I explained what had happened and texted him a photo of my knee, not thinking much about it, prepared for a suggestion to treat it with Benadryl ointment for some sort of allergic reaction to the plastic coating on the gel ice pack.

The phone rang two minutes later. It was Arian.

“Martine,” he said, “You have frostbite or technically frostnip.” 

“I have what?” It took me a couple of seconds to zero in on what Arian had said.

He continued. “I’ve looked it up. You need to run warm water on it to warm up the tissues. Don’t use a heating pad or hot water.”

“Arian, how do you get frostbite from an ice pack?”

“Frostnip,” Arian repeated. “It’s the beginning stages of frostbite.” He then explained how it occurred and suggested that I watch it carefully and see my doctor the next day. He warned that infection could set in and encouraged me to follow up with my doctor. He also suggested Advil or Tylenol for any pain.

To be honest, I didn’t really believe him at first. Who gets frostbite from an ice pack? But I did as instructed and ran warm water over the area. The swelling reduced considerably, as did the heat that had radiated from the skin. This led me to research frostbite from icepacks. Much to my surprise, I came across a number of photos that showed affected skin identical to my knee. Several credible websites confirmed the information and treatment that Arian offered.

I started thinking about the probability that many people don’t think of their pharmacist as a resource. But in fact pharmacists offer a broad spectrum of services and are easily accessible. I’m not recommending that you replace your physician with a pharmacist or to contact your pharmacist instead of your physician. This is my disclaimer.

Tips for using your pharmacist

1. Use one pharmacy to fill your prescriptions. This allows the pharmacist to catch medication errors and drug interactions. According to the JAMA article, Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit, studies show that a pharmacist’s retrospective review of medication orders prevents errors. You want your pharmacist to catch errors before they happen.

2. Establish a relationship with your pharmacist. This is a lot easier with a smaller pharmacy chain or independent pharmacy, rather than a big, nation-wide chain.  

3. Review your medications with your pharmacist. Ask questions about them, such as possible side effects, interactions with other medications and supplements you might be taking, time of day to take them, if they should be taken with food, and more.

4. Generic medications come in all shapes, sizes and colors. Ask your pharmacist questions if you don’t recognize the medication you receive.

5. If you’re having trouble managing your medications, make an appointment with your pharmacist and ask him/her to help you.

6. Many pharmacists offer wellness screening programs for osteoporosis, diabetes, cholesterol, and immunizations, nutrition and diet counseling, and more. Many are also equipped to treat minor medical ailments. Ask your pharmacist if he/she provides these services.

Not every pharmacist is as knowledgeable and kind as Arian, but they are out there. You just have to look. Initiate a conversation with your pharmacist and decide if he/she is a good match for you. Ask yourself these questions: Do I feel confident in his/her expertise? Am I comfortable asking questions? Do we communicate well?

Pharmacists don’t get paid extra for phone calls or in–person consultations. Consider writing a note of thanks for extra time spent with you. If your pharmacist has gone the extra mile for you, consider a small token of appreciation. Pharmacists are generally under appreciated, as I discovered by interviewing several for my latest book.   

Even though my knee was much improved by the next day, I did, as Arian suggested, follow up with my PCP.

 

I welcome your comments.  

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According to the Medscape article, 15-minute visits take a toll on the doctor-patient relationship, physicians and patients alike are feeling a time crunch. 15 minutes per visit is the average, but some primary care visits are shorter. Part of the problem, the article states, is that millions of patients are now seeing doctors for the first time under the Affordable Care Act with an assortment of medical problems that have not been previously addressed.

To make matters worse, many physicians are facing greater financial pressures as reimbursements decline from health insurance plans through the health care law exchanges. Doctors are cramming in more patients to make ends meet.

15 minutes or less per office visit has been the norm for a while, as far as I know, and it has in fact crimped doctor-patient interaction. Effective communication between both parties takes time and so does the relationship that it supports. Studies show that if a patient bonds with a physician, creates a successful partnership, and the patient is an active participant in care, that there is an increase in quality of care and treatment adherence, fewer medical errors, and possibly reduced cost.

I talked with a physician today who has the luxury of spending time with patients. She asked, “How can you reduce the number of diagnostic errors if there is less time to review test results carefully, converse with patients, listen to their stories and perform exams?”

Both patients and physicians are in a bad spot. Health care reform, in some ways, is a controlling wrangler. Patients are flooding the market, there is a doctor shortage, reimbursements are declining, and health insurers are restricting choice of doctors and hospitals to keep costs down. In addition doctors are accepting fewer Medicare and Medicaid patients because of the low reimbursements and high administrative costs.  

Where does the patient-provider relationship fall in the midst of all of this? According to The Ochsner Journal, Doctor-Patient Communication-A Review, effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart of medicine and a central component in the delivery of health care. That communication cannot be conducted successfully when a doctor is looking over his/her shoulder at patients lined up in the waiting room.

Which leads some physicians to offer cash-only care and to not accept health insurance at all. This allows them more time with patients. More doctors are now skipping insurance to offer cash-only care. This kind of direct pay from patients has been accelerating as a result of the Affordable Care Act. The unfortunate piece is that many patients cannot afford cash-pay, are stuck within the confines of the 7-15 minute medical encounter, and try to make the most of it. Which is most of us, I might add.

Stanford University Hospital offers virtual doctor visits in their dermatology department as a way to save time and increase access. They claim high quality and low cost. Watch video here

What are patients to do if they have 7-15 minutes with their physicians?

Tips to make the most of your time with your doctor 

1. Come prepared for the visit. Ahead of time, create a list of questions you’d like to discuss with your doctor. This allows you to think about what you want out of the encounter. 

2. Come prepared with your top 1-3 medical concerns.

3. Come prepared with copies of pertinent medical records. There’s nothing worse than requesting your records to be sent to your doctor and arriving for your appointment only to realize that your records didn’t show up. This can be a definite time-waster. 

4. If you need a new diagnosis, create a symptom diary ahead of time and track your symptoms daily. This includes the time of day symptoms appear, what makes then worse or better, if there was a physical event that accompanied the onset of those symptoms, and when those symptoms started. Share the information with your doctor. This supports your doctor’s efforts to arrive at an accurate diagnosis.

5. Humanize yourself to the doctor. In a few seconds you can let your doctor know a little about you so you will be remembered. Several health psychologists I interviewed for my latest book, The Take-Charge Patient, suggested finding common ground with the doctor such as shared interests, children, grandchildren and activities. You’re establishing a personal connection. 

Granted, health care reform offers a number of very positive changes. But there are some issues that need to be retooled to make the new system work for both physicians and patients.

 

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