The Dangers of July in the Hospital

According to an article published in the Journal of General Internal Medicine, A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents, counties with teaching medical hospitals experienced a 10% increase in fatal medication errors as compared to counties without teaching medical hospitals.

First, what is the July Effect? It represents an entire transition in the hospital, during which medical students become interns, interns become senior residents, and second or third-year residents become chief residents. All of the fellows are just starting out in their specialty of choice, and there are new attendings, fresh out of residency, who have entered their chosen field. Leadership in the hospital changes all at once, and this makes for a dynamic and uncertain environment as everyone tries to adjust to their new roles.

Secondly, what are the specific effects of this phenomenon? This question is open to interpretation – the recent study suggests that one of the effects is an increase in fatal medication errors. However, mistakes in the hospital (or in any system) only occur when a series of “errors” or “oversights” are made in unison. All of the safety nets which prevent fatal medication errors must have failed. What are these safety nets?

1. Residents, fellows, and attendings should adequately supervise the new interns who are ordering medications.

2. Medication doses on the electronic ordering system should have certain restrictions.

3. Nurses are often the only staff in the hospital who have access to the medications, and we rely on them to administer them properly.

4. Interns should be educated about when to ask questions, and they should be provided with very clear guidelines for basic medication dosages. They should know where to locate appropriate dosages, whether through an online reference or the hospital pharmacy directly.

5. Pharmacy can play a role in overseeing medication orders in the computer.

This is a list of fail-safes which, if effective, minimize the risk of fatal medication errors. There are similar back-up plans in place for other fatal medical errors, including everything from cardiopulmonary resuscitation to surgical procedures. It is only when every back-up fails that an error occurs.

Thus, if the July effect is real (and it seems hard to dismiss, based on evidence and common sense), the question is not, “Whose fault is it?” Instead, the question is, “How can we strengthen the safety nets that we have or create additional ones in order to minimize these errors?”

The first and most important step is to acknowledge that these errors are happening. Just as physicians have a difficult time coming to grips with their own mortality or invincibility, they also have a difficulty time confronting their mistakes. Guilt, fear of retribution from colleagues or patients, humiliation, or even arrogance can drive physicians to sweep their errors under the rug. And these emotions only build on themselves, so that the entire community is caught in a negative cycle of denial and shame rather than constructive analysis.

The second step is to create more fail-safes if necessary. But this can only be done if we admit to our mistakes and work together, with physicians, nurses, and residents, and commit to making our hospitals safer for patients.

Defensive Medicine Supersedes Quality Medicine

A recent article in US News and World Report, Most U.S. Physicians Practicing ‘Defensive Medicine,’ claims that physicians are ordering more tests and escalating the work-up of sick patients, all in the name of defensive medicine. Is it true? Absolutely. It is especially true in the emergency department, where we have one shot to get things right, or else. Ironically, by practicing defensive medicine we are not practicing quality medicine – and isn’t that what patients really want? Training during residency has changed over the last two decades, and the emphasis has shifted from performing a good history and physical examination to ordering and interpreting laboratory tests and imaging studies. We no longer take the time to listen to our patients. Instead, we have started clicking as many buttons on the computer order set as we possibly can in order to cover every life-threatening diagnosis. But even in the world of technology, numbers, and images, medicine remains an imperfect science.

I vividly remember a lecture during medical school on cardiology. The professor, who was in his 80s at the time, taught us how to use the stethoscope and explained the subtleties of different heart sounds. He gave us a CD, which is now sitting somewhere in my closet under a film of dust. There is an art to distinguishing a rub, ejection murmur, opening snap, split S1, gallop, click, or extra heart sound – especially when the sounds are so soft that they can barely be heard in a completely silent room. It takes extensive practice and training to improve at this – but rather than using our stethoscope, we spend time looking at echocardiograms and troponin levels. As another example, there have been several articles written on how poorly residents and attendings perform a neurologic exam in the emergency department – a good neurologic exam takes time and requires the full, undivided attention of a perceptive clinician. Some people have a knack for this and others do not – regardless, physician training in these areas is far from what it used to be. Over the last year, I can count on one hand the number of times I have been accompanied at the bedside by an attending who lays his hands on the patient.

Our predecessors were better able to gather essential pieces of clinical data from a physical exam because it was the single tool they had. In the 1960s surgeons could only use their hands to diagnose appendicitis. The advent of new medical technology, various imaging studies, and more laboratory tests has been both helpful and detrimental – for it has allowed us to gather more information for diagnostic purposes, but it has also given the wrong impression that this information is more “certain” than or is a substitute for the physical exam. Laboratory tests and imaging studies, just like the physician’s own hands, are an imperfect science. Although the perception is that patients benefit by getting a myriad of lab tests and imaging studies, they do not. These tests have as many limitations as the history and physical exam, and they only gain their significance when analyzed by a physician in the broader clinical picture.

Rather than accepting the inherent limitations of tests, clinicians have begun to practice test-centered medicine rather than patient-centered medicine. This causes huge delays and expenses in patient care. It also places patient at risk for (1) being treated unnecessarily for incidental findings and (2) being exposed to unnecessary radiation. Furthermore, it alienates patients even further from their physicians – and this, perhaps, is the greatest cause of increased lawsuits and patient dissatisfaction, which starts the cycle of practicing defensive medicine all over again.

Chaos, Cacophony, and Conundrums: The Rhythm of a Night in the ED

Sunday nights in the emergency department. Patients singing in discordant tones, taunting one another through the curtains, commiserating together about their subpar treatment by doctors and nurses. People from all walks of life screaming in unison… The article by Teri Reynolds, who worked as an emergency physician in Oakland, comes to mind, Dispatches from the Emergency Room. There is one patient who regularly greets him with “Yo bitch, get me a sandwich.” It was one of those nights.

(Tangent: I am often frustrated by the way the emergency department operates – I wish that we could take care of patients more quickly than we do. But so often our hands are tied. More on this later.)

And now for the thoughts of today: the doctor persona. I think this is something which I have subconsciously developed over the last year. I had a moment on my shift yesterday when I realized this – I was talking to a patient and noticed that I had a comfortable, confident, but very informal and honest manner towards him. He seemed content. I was only aware of my interaction because a fourth-year medical student, who was standing in the background, was glancing in our direction with some kind of interest or curiosity – as if this were unfamiliar to him, to act this way with a patient. As I observe fourth-year medical students now, I realize how stiff they appear – not comfortable in their own shoes, if you will. And it’s no wonder – here they are wearing white coats, for the first time, still trying to figure out what that means for both them and their patients.

One of the small-town doctors who trained me used to say that being a doctor is similar to being an actor: you need to walk into the room with a persona and establish rapport with a patient right away. First impressions are everything and when you walk in that door, shake the patient’s hand, and introduce yourself, you set the tone for the visit. You are on stage. You are not exactly a friend, nor are you an authority figure. You are a physician, a provider of medical care. I view my role as more of an advisory one – I have an area of expertise outside of my patients’ which gives me the ability to care for their overall health as best I can. But I am well aware that my medical opinion is not the only medical opinion, and I am also aware that, just as with everything else in life,  nothing is 100%.

Should we really act as physicians? Perhaps that word gives the wrong impression. We cannot completely be ourselves when we walk into the room – we cannot talk about our woes, our frustrations, our personal problems, or even our medical problems. Our job is to be an ear for our patients, and to respond in the way that they need. Maybe this is not acting as much as it is focus, and purpose. Just like an athlete preparing for and competing in a race, we need to be focused on our task in order to do it well – we need to be fully in our role, in the mindset that we are here to accomplish something specific. The rest of our soul needs to be set aside for the moment.

Nobody teaches us the “doctor persona.” We are taught the skills of listening, of delivering bad news, of responding to a patient’s concerns, of being sensitive. But, over the course of training in residency and afterwards, everyone develops their own style. Some people walk into the room with such an extroverted style that they are almost oppressive to the patients. Others enter with such meekness that patients wonder whether their doctor is really present or not – these physicians often let the patient run the show. Others are more middle of the road. Some use sarcasm or humor, others use a gentle approach. Many use a false sense of optimism.

We are doctors just as we are human beings – trying to establish rapport with patients, to earn their trust, to respond to their needs appropriately. And we struggle in deciphering our role in the physician-patient relationship just as people struggle in all kinds of relationships with families, friends, co-workers, and children. Often our personal tendencies in “real” life become our tendencies as physicians – and depending on the patient and his or her needs, these can be viewed as assets or flaws.

Sometimes our patience runs thin – as mine did last night when I felt like I was working in a veritable jungle. Let’s take that metaphor a bit further: the ED can be a place where it’s every man for himself, where patients fight to get to the top of the CT scan list, where impatience and anxiety run high. This is living on the edge – where the next storm of a full trauma rumbles through the ED at any moment, bypassing all the patients in the hallway – blood, crushed limbs, and broken faces flying by them at lightning speed as they make their way to the trauma bay. And the sounds are of the jungle – one woman retching over and over again, one man belting out notes like a hyena, another content in his discontentment as he incessantly belts out “doctor, nurse, doctor, nurse,” and still another who shouts in response to this “they all went home.” Another who is crying, crying, her mouth gaping open, sobbing uncontrollably. Another who is shouting “I am going to die, I am going to die.” And the smells are of the jungle, or worse – the indescribable smell of melena, the smell of gangrenous, infected feet, the scent of clothing which has not been washed for days.

As I go through my shift, a drumbeat pounds in my head. Think Jungle Rhythm, African Drums And Soukouss. It’s only the drums or sheer laughter that can get you through a night like this in the emergency department – and if you start laughing your patients and colleagues look at you oddly (they don’t always see the humor when they’re smack dab in the middle of it).

When it comes down to it, emergency medicine is expected chaos. As soon as you grow accustomed to that, your feet fall into rhythm and you bow your head. You let the rhythm of the ED, rather than your own breath, set the pace. You listen to it, embrace it, allow it to overtake you like a wave. And you march on through those 12 long hours, in a job which so few people could ever truly imagine, sometimes helping patients, more often helping them help themselves. And laughing every now and then (as inconspicuously as possible) in pure disbelief, considering with gentle wonder if you really signed up for this in the first place – but only for a passing moment until the next episode of expected chaos booms through the doors.

On CT Scans

A recent set of articles on the June issue of NEJM address the issue of CT scans, NEJM — Is Computed Tomography Safe? and NEJM — The Uncritical Use of High-Tech Medical Imaging. The emergency department is one of the biggest culprits – over the last decade, CT scans have become the imaging modality of choice. It has become part of the package ED patients receive: name band, urine sample, ekg, a listen to the lungs, and a CT scan before you go on your way – just to make sure we’re not missing anything. Although the definitive risks vs. benefits of CT scans have not been studied thoroughly (the long-term effects will need to be examined in the coming decades), the cancer risk from abdominal and chest CT scans is indubitably substantial.

The CT scan is the modality of choice for patients with traumatic injuries, head injuries, and abdominal pain. It serves as a definitive screen for a myriad of medical conditions which may or may not be picked up by other imaging modalities: cholecystitis, appendicitis, small bowel obstruction, and the list goes on. But just like anything else in medicine, the benefits of the test are accompanied by substantial risks – in this case, the risk of malignancy, which may be as high as 1 percent for a single scan.

The importance of discussion around CT scans will be important in the coming years, especially in the emergency department, where time is of the essence and patients can be whisked away to the donut hole without a sense of what the consequences may be. One of the major tenets of the Hippocratic oath is First, do no harm. With the advent of new machines, imaging modalities, and medical technology, we must realize as physicians that we still have the same responsibility with these tools as we do in the operating room or in our office. The goal for the near future is to reduce use of CT scans in the ED and to transition to alternative, less radiating modalities such as MRI and ultrasound when possible.

The Story Behind Medication Noncompliance

The news of the day is that a program in Philadelphia is now paying patients to take their medications. Refer to the New York Times article For Forgetful, Cash Helps the Medicine Go Down. The concept makes sense in theory – the failure of patients to take their medications is one of the most common reasons that patients return to the hospital and are readmitted shortly after they are discharged. One of the most important components of a patient’s history and physical examination is the question of “medication noncompliance,” the term used by physicians to designate whether a patient is taking his or her medications – or not. Many a hospital chart carry to the notorious phrase “Patient has a history of med noncompliance…..”

This topic raises an important question: how can you convince a patient to take his or her medications? Those who take their medications do so because they want to live as long as possible; some simply do it because they are responsible, conscientious individuals by nature. But the hustle and bustle of daily life often get in the way of taking medications, especially those that are timed inconveniently (exactly at dinnertime, just before bed, or greater than two times per day). For the elderly, the mentally impaired, or the physically impaired, insurance companies will often pay for a visiting nurse to come by, at least once a day, to ensure that a patient gets at least one set of the most vital pills. But what about the rest of us? We are left to fend for ourselves in the world of pills – and it is not uncommon for patients in this day and age to have a laundry list (anywhere from 10 to 20) daily pills. I know this first-hand: I wrote an entire schedule for my grandfather’s medications on a detailed sheet for my grandmother a couple of years ago after his first heart attack. She has been following it ever since (there is a reason why married men come to the ED more often, tend to live longer, and tend to be more medication-compliant than men who live alone). And I assure this, this is no easy feat for people in their 80s with little to no education beyond the high school level: but she manages, and she does quite well. She has a strong motivation to make sure he never misses a dose and will interrupt any event to ensure this.

This brings us, in a rather disorganized fashion, to the news story I cited above: what to do about the patients who do not take their medications, and who therefore are a financial drain on the entire health care system because of the costly complications and hospitalizations that result?

My firm belief is that if these patients do not have a strong enough incentive to take their medications so they can live longer, healthier lives, then the long-term benefits of providing financial incentive are likely to be minimal. In the short-term, the rewards may be substantial enough to elicit a response. An isolated lottery-system or patient study is not an accurate depiction of the real-life scenario: patients will have to be taking these medications for decades. Secondly, the issue of monitoring medication compliance in a non-controlled setting, i.e. the real world, is also an issue: no method is sure-fire (unless perhaps it is prohibitively expensive). Lastly, one of the most important concepts about a “medication list” is that it needs to be revised (often 3-4 times a year) in order to deliver maximum benefit to the patient; so not only do patients need to take their pills, they need to see a doctor regularly and get re-evaluated in order to determine if these are the right medications and the right dosages.

The way to truly get at the question of medication noncompliance is to go to the source directly: the patients who do not take their medications. Why don’t they take them? Some people have access issues, financial or otherwise, and simply have not been able to get the medications they need (try making one phone-call to a health insurance company to address these issues, and you will immediately see the obstacle in the way). Increasing accessibility, through transportation or financial aid, would give these patients the chance to take their medications. Others have pills which are timed so frequently or so inconveniently (which require them to wake up in the middle of the night, for example), that it becomes a monstrous task to be fully medication-compliant. This may require either a re-working of their medication schedule (to take more pills at the same time), or perhaps a change in medication to something that is taken less frequently (doctors often forget how important this is when prescribing medications).

Still others have not been properly educated about the importance of their medications in the vernacular. Many patients have told me that they do not have high blood pressure because they were once prescribed a high blood pressure pill (which they may or may not have taken) – in essence, they view an antihypertensive as an antibiotic that can be used as short-term treatment for a short-term problem. I have had other patients tell me that they never had a heart attack because they were taken to the cardiac catheterization lab and were “fixed.” Nothing is farther from the truth, and as physicians we are responsible for making sure patients understand their own medical history and their own medications. I have had many patients raise their eyebrows at me and look at their medication lists with a newfound respect when I explain to them why these medications are essential to their health.

Other patients do not take medications because of the google-drome. When you ask a patient why he or she is not taking a particular medication, you may get an answer that sounds something like this, “Well, I went on google the other day, and there was a long list of side effects, and so I decided it just wouldn’t be a good idea.” The issue of side effects is one that can easily be combatted: a simple conversation with the patient at this juncture can change his or her perspective. Just like everything else in medicine, it’s all about risks vs. benefits – that is what we as physicians are trained to analyze. And with close follow-up, patients can be rest-assured that we will monitor them closely for side effects and address any that are unpleasant as best we can, either by treating them or by trying a different medication.

I am leaving one group of medication non-compliance offenders out. Let’s recap: there are those who don’t have access, who have a very demanding medication schedule, who don’t understand the importance of their medications, and who are wary of the side effects. All of these issues can be addressed. And then…drumroll please. And then there are those who simply do not want to take their medications. Astounding, astonishing, pure heresy. How could this be possible, in a country as pill-happy as we are? Because they’re depressed, or lazy, or simply don’t want to follow orders or to inconvenience themselves. Maybe they don’t believe in medication. Maybe they just don’t feel like it. And, if you refer to the quote which serves as the theme for this blog, maybe they aren’t totally off base anyway.

And for these people, there are fewer solutions. But again, I don’t believe that financial rewards are a viable long-term solution. If the fact that these individuals are a drain on the health-care system is an issue, maybe it should be addressed with negative incentives. For example, if patients do not take their medications or do not schedule or show up at visits with their primary care physician, maybe their insurance rates should be higher. It would only seem fair, given the extra financial burden they impose on society through their expensive hospital admissions. Or we could try a gentler approach: coddle them a little bit. Offer them the option of a visiting home nurse to help them administer medications, or even just to help them in the kick-off stage for a short period (2-3 months). This way, that they can get some assistance in setting up an organized system for taking their medications (pill boxes, alarm reminders, etc.), if they are genuinely interested in taking better care of themselves.

The long and short of it is that there is no easy solution, and although a simple financial incentives program has its appeal (after all, who doesn’t love a quick, clean solution to a hefty problem?), its complications abound. What’s worse, it sends the wrong message to society: as physicians, we send the message to our patients they we will not only work to serve and care for them as best we can, but we will now pay them to take better care of themselves (many a physician would roll over in their graves at this, but that, and the concept of the physician-patient contract, is a story for another day). And by the way, for all of you medication-compliant patients out there, you can have the inherent reward of a longer, healthier life, but we’re not going to bother sending you money. This is a bold statement. Whether intentional or not, it seems like some sort of implied punishment. Not to mention the effect this message will have on children: little Betty, you need to take this spoonful of distasteful medicine right now for your ear infection, but don’t worry, because when you grow up, life will get better: somebody will pay you to take it.

Providing a reward system to people for something that is inherently good for them, and that gives them many benefits on its own, is digging into a bottomless pit, where patients will want more and more and become more and more greedy until the burden on the system and on society is substantial. Perhaps a long-term moderate-reward lottery system for all patients who take their medications (let’s say one winner a year) could provide some form of incentive for some people…but again, it doesn’t make sense that any rational individual would suddenly and enthusiastically start playing a lottery for cash rewards, when he clearly isn’t setting himself up to win in the lottery of life in the first place. But it’s America after all, so maybe a few people will crawl out of the woodwork to surprise us. But we’d be going on a wing and a prayer – and maybe, sadly enough, that’s the best we can hope for.

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