Category: Hospitals

You’re a Doctor When You’re Not Giving Anesthesia???

I had to read the title of this post several times to figure out what it meant. Maybe you did too. Check this out. What you will see is a conversation between an anesthesiologist and a confused patient and his wife. Quite simply, these people were confused because they believed that only CRNA’s/nurse anesthetists gave anesthesia. The idea of a “doctor” giving anesthesia was apparently totally new to them.

So what caused this confusion? The posting physician wonders if sex bias was the cause. Or maybe both the anesthesiologists and the anesthetists who had cared for the patient previously had introduced themselves by their first names, muddying the waters. Based on a recent personal experience, I think that the answer is more fundamental.

So here I was, a week or so ago, at the Surgicenter on Hilton Head Island. Like the patient described here, I was in for an outpatient endoscopy. In pre-op, the anesthesiologist stopped by my cubicle, asked me the usual trick questions like “What did I have for breakfast that morning?” (I gave the correct answer… Nothing!), etc. He introduced me to a young lady who, he said, would be “My anesthetist.” All good.

As my gurney got pushed into the endoscopy suite, both the anesthesiologist and the CRNA were in the room. A quick discussion between my gastroenterologist and the anesthesiologist came to the bottom line of the latter saying “I’m going to do this one.” The MD rather than the CRNA.  He then told me he was going to administer the propofol, and off I went to lala land with no opportunity to inquire as to why he had stepped in for the CRNA in my case. 

Bottom Line. Given the verbal exchanges described above, it is little wonder that the average patient could be confused about the roles of the anesthesiologist and the CRNA. Who does what? When? Why?

Interestingly, the piece concludes with the perspective that it is really important for anesthesiologists to “promote their brand” as effectively as CRNA’s do. Make sure to introduce themselves as “doctor.”  Explain that they will be “supervising” the CRNA.

The benefit of this communication? Letting the patient know that he has not one but two people involved in administering his anesthesia and in monitoring other vital functions. Such clarity, I would argue, would be far preferable to the situation in which I found myself last week, with my last waking thought being “Why the last-minute crew change?”

In brief, while the author seems to believe that this discussion is about respect, I believe it is more fundamentally about patient confidence.

Why Did This Take So Long???

Check this out. What you will see are descriptions of new high-tech hospital “behavioral health areas” being instituted by some hospitals to promote “calmness” in young, agitated patients awaiting care. 

This makes a lot of sense. Juxtapose the spaces described in this article, that can be custom-tailored to meet the psychological needs of a specific patient, with the cold sterile spaces in which such patients are often detained which increase, rather than decrease, their level of agitation. 

Significant literature exists on the impact of architecture and interior design on behavioral health and psychological wellbeing. One of the classics is a study that demonstrated that if you put mental patients in a building with LONG hallways, like the old state hospitals, they respond by pacing up and down those hallways. Incessantly! 

Bottom Line. While the institutions referenced in this article are certainly to be commended for redesigning their mental health spaces to be more suitable for younger patients, let me ask one more time.

What took them so long???

How to Become a “Hospital Warrior”

Check this out. What you will see is the story of a layperson who has learned the hard way, i.e., by fighting for appropriate medical care for her husband, how to work the hospital system.  Terminology is, as always, important. At the Hilton Head Volunteers In Medicine Clinic, we use “Patient Navigators.” Frankly, many of our patients have never had a doctor before, don’t speak English, and need help getting to the right person at the right time. That’s different.

“Patient Advocate” is closer to what is being talked about here, but still falls short of some of the visceral feeling that is being discussed in this book. What we see in this tome is the advice that someone needs to actually get belligerent to get the right care for a patient in some circumstances in some hospitals.

An unfortunate case in point. At a friend’s birthday party a couple of weeks ago, on a Saturday night, I met a great couple. Happy. Healthy. Beaming. She in her 50’s, he in his early 60’s. That day, he had won a 5-mile kayak race. They had gone to a wine tasting, and now he was dancing at the party. My wife and I left at about half time, but the party continued until 1 AM. He had a difficult time walking the short distance to his home. Couldn’t breathe. Not COVID. In an ambulance to a local hospital at 2:30 AM. Three days later, I was told he was going to be intubated. The next day, I learned that in the process of being medevacked to MUSC, our tertiary care hospital in Charleston, he had died in the helicopter. A full five days after initial admission to the local hospital!!!

Bottom Line. As I looked at this book’s URL, I wondered. I wondered whether if a “hospital warrior” had been fighting for his care, would the chopper have lifted off days earlier and he might still be alive?

We’ll never know!  

“Slow” Breaking Health Care News

No, that’s not a typo. I know, most of us are all too used to hearing Wolf Blitzer tout “breaking news” on CNN every night, with the word “fast” being implicit in this pronouncement. But that’s the point of this article.

You see, Philadelphia’s Hahnemann hospital closed its doors in 2019. Seems that the “investment banker” who owned the hospital thought it wasn’t making enough money, and that was that. This of course raises the question as to whether healthcare is just another business with the primary goal of making money, but that discussion is for another day.

I moved from Philadelphia to Hilton Head Island, South Carolina about a decade ago, and had lost track of the fate of this once important medical institution in the city. I was a researcher on the staff at Hahnemann years ago, and I found its demise neck-snapping.  But not nearly as neck-snapping as did the interns and residents whose training was, to put it mildly, interrupted by this closing. Nor the medical staff. Nor the residents of North Philadelphia for whom Hahnemann served as the “safety net” for medical care. Could anything have been done to avoid this eventuality? We’ll never know because the closing simply never got much attention. And that’s the problem!

Bottom Line. The authors of this article make a great point. It’s hard to get people to focus on a complicated and slow-moving health care story like this one when the daily headlines are yelling non-stop about new COVID-19 infections, hospitalizations, and deaths.

Stand back and think about it. Isn’t this a problem that transcends the closing of Hahnemann? Aren’t many of the most societally important stories so “slow breaking” that they don’t make it into the headlines, and as a result don’t get much attention? Think global warming! 

And that’s a problem!

The Pandemic And Medical Malpractice

Want to know what one of the longest-term side effects of the COVID-19 pandemic will be? Easy one! Growing numbers of malpractice cases against physicians and hospitals.  

Check this out. What you will see is a primer on the changing face of healthcare litigation resulting from the coronavirus. Example. Oncologists in my On Doctors’ MindsSM study are telling me that they are seeing “stage shifting,” i.e., patients presenting with later and less treatable forms of cancer due to delayed/missed colonoscopies, mammograms, etc. What if these delays were caused by a hospital shutting down “non-emergency procedures?” Liability???

AND. If a case is filed, what impact on outcomes results from the trial being conducted via Zoom???  

Bottom Line. Explore any of the topics included in this article’s pull downs. And remember. The healthcare institutions and practitioners being discussed here are our customers. What impact do we think this all will have on them…and on your business???

Barney Cohen, Healthcare Attorney

Check this out. What you will see is medical politicking at its worst. A surgeon bizarrely charged with collecting cash from a patient at the point of care rather than going through normal billing procedures. Based on this infraction, the doctor’s reappointment to his institution’s faculty was placed in jeopardy. Not liking the handwriting he was seeing on the wall, he hired Barney Cohen, Healthcare Attorney. Long story short, Barney was able to get the matter dismissed. Turns out that the hospital had no policy against doctors collecting cash. AND. The fact that one of the physicians sitting on the board that was reviewing the matter was his “competitor” was seen as hopelessly tainting the process.

Bottom Line. So, what is the point here? Easy one! We need to disabuse ourselves of the notion that “medical malpractice” is the only cause of physician legal woes. Hospital politics can be just as onerous!

Don’t Wake Me Up Again!!!

Check this out. What you will see is not a happy story. It is the tale of an ICU nurse who after decades of fighting the good fight for her patients, just finally had to quit.

The interesting part of the story here is the part of ICU nursing that finally did her in. Sure, critical care carries with it more than its share of heartbreak and death. Comes with the territory.

That’s not what got her. The last straw was working hard to maintain an 86 year-old patient during her last days. Suffering unnecessarily. Because her family couldn’t let her go.

Bottom Line. Interesting juxtaposition. So much of what we see on TV news these days is about “exclusive access to one of the nation’s busiest ICU’s.” Patients on respirators, clinging to life after being cut down prematurely and summarily by the deadly coronavirus. Wham, Bam.  

But here we see a different kind of stressor on ICU personnel. The all too frequently encountered life that has been forced, yes forced, to go on too long. Interesting that is not the pandemic, but the far more routine end of life drama, that did this ICU veteran in!

Restraints In The ER

No need for you to pay for access to the full article in the journal to which I am referring you. The synopsis you get for free is all I want you to think about today.  

Check this out. What you will see, even in this synopsis, is thought provoking. We are told that patient “agitation” in the ER is:

-A growing problem

-Typically dealt with by applying restraints and/or hoods, and the use of sedatives

-Likely to cause physical and/or psychological damage to the patient, not as a result of the agitation itself but as an outcome of the restraints employed. 

I am sure that this has always been a problem, but in the post George Floyd era, it is clearly, and appropriately, getting increased attention. 

Bottom Line. But what to do? Very appropriately, the authors call for the use of “evidence-based algorithms” to decide which coercive measures to employ in a particular set of circumstances.    

Nice words in an academic journal, but difficult to implement when in the middle of the night, you are confronted with a large, drug overdosed and flailing patient who is spitting at the healthcare providers while claiming he has COVID.

I am thinking that excellent practical training, closely supervised experience and a large dollop of common sense are what is needed to deal with this increasingly important issue.

Then again, doesn’t everything sort of work that way?

Women Are Better Hospital CEO’s!!!

That is a bit too general a statement, so I need to go back and qualify it. There are all kinds of measures of hospital CEO quality. Things like the profitability of the institution, for example, or relative freedom from adverse litigation. That’s not what we are talking about here. 

Check this out.  What you will see is a study demonstrating that women hospital CEO’s improve the “interpersonal care experience” in their institutions faster than do men, especially in the most “complex executive job environments,” like hospitals that are large, in very urban environments, or both.  

Bottom Line. That finding got me to wondering. Why is this the case? By way of response, the researchers argue that this is a demonstration that CEO’s “personal values” wind up being reflected in the institutional setting, and that women are more prone to value “patient centeredness” than men.  

This all reminds me of a blog I posted several months ago, in which I directed you to a physician’s blog that offered 12 reasons why female doctors are better doctors than are their male counterparts. So. All of this leads inexorably to a hopelessly sexist and sarcastic question: What are men doing in medicine anyway?  

Hospital Innovation In The “New Normal”

Check this out. What you will see is a description of three areas in which hospital innovation has been accelerated by COVID-19. These include “Alignment of Incentives.” With the pandemic putting significant strains on the finances of many hospitals, the movement toward value-based medicine has been significantly accelerated. Concepts like “Command Center Management” have evolved to accelerate decision making and increase efficiency. Whether this will help the hospitals’ bottom lines remains unclear.

“Market Competition” is another area where hospital innovation has been accelerated. Telehealth, for example, is a capacity that every hospital now must offer. In fact, excellence in telehealth is rapidly moving from being a differentiating factor to becoming “table stakes.”  

“Consumerism” is the final area where Covid-19 has accelerated innovation. Patient demands on healthcare have radically changed with the pandemic. For example, patients are increasingly evaluating institutions based on the accessibility and features of their “digital front door.” 

Bottom Line. The common theme here? Innovations that hospitals were moving toward pre-COVID have been greatly accelerated by the pandemic. Over the course of the rest of 2020, it will be important for us to keep our eyes on what else is going to change in the hospital environment.