Tuesday, December 27, 2005

How MGH Executives Think

An article in this morning’s Boston Globe under the byline of Christopher Rowland reported that Controlled Risk Insurance Company, malpractice carrier for a number of Harvard teaching hospitals, had given out several grants to support risk prevention studies.

One grant of $50,000 went to Dr. Shan Liu, an Emergency Physician at Massachusetts General Hospital, to support a study of risks associated with long patient stays in the emergency rooms of MGH and its affiliated hospitals.

It prompted me to compare the size of the grant with the annual expenditures by MGH which, according to data published by the American Hospital Association, were $1,670,451,000 in 2004.

One would think that if there was reason to suspect that operational problems in its emergency room might be putting patients at risk, MGH might have invested $50,000 of its own money in an investigation of the matter.

But apparently that is not how MGH executives think.

Sunday, December 25, 2005

Physician Power

A posting on the subject of the exercise of physician power prompted the following comment from Neil Whipky, Hospital CEO in Florida:

Here is a story from my first job as a hospital administrator, back in the early 90s. We had an elderly female patient who was obviously getting ready to "cross over the final river". She had but a few hours left, at most. She was in our ICU and unconscious with no family support. Her physician came into the unit and wrote a page full of orders for various tests and medications. Then at the end he wrote in "DNR".

I assume everyone knows that DNR means “do not resuscitate;” medicalese for “if she dies, don’t try to save her.”

Friday, December 23, 2005

Inappropriate Prescribing – A Case in Point

My Power Without Accountability posting about inappropriate prescribing drew the following response:

The subject of doctors over-prescribing addictive drugs sure hits home with me. My brother died in 1960, just 8 months old. My mother had a break down and was tied down and pumped with drugs. After that she saw a psychiatrist who prescribed cloryl-hydrate (not sure on the spelling on that), which I'm told is one of the most potent drugs around and is now rarely used. After a few years, he saw her one time a year and continued to prescribe the meds, and over time gave her higher and higher quantities. At some point she began drug seeking from other doctors and added more uppers and downers to the other med.

What started as a patient trusting that her doctor knew what was best ended in a highly addicted person who had yet to deal with the loss of a child. When I was old enough, I arranged for an intervention and got her into treatment, which did not completely succeed because she still uses some, just not as much and not all the time. It’s an unspoken compromise within the family, but we keep a close eye on her to make sure she does not do more than what I'd call a binge now and then.

The kicker? While she was in treatment, I tried to contact the psychiatrist to tell him to stop prescribing the drug. He had been retired for almost 5 years, had not even seen my mother in all that time yet continued to supply her with drugs. I called the board and reported this, and he lost his authority to prescribe meds to anyone ever again.

I don't know much about drug monitoring programs, but I do think some of the responsibility lies with the friends and family members of addicts. There are many things that can be done, I also called all the drug stores in our area and let them know my mother was getting drugs filled at all of their stores, and from a variety of doctors. They were able to watch for her name to come up, and if they had concerns they communicated back and forth. The pharmacists went so far as to talk to the doctors who were prescribing the meds, at my request.

I think that addiction to prescription medications is one of the least talked about of addictions, and also one of the most shameful addictions. It is still kept behind closed doors. As a social worker, I've worked with alcoholics and people addicted to street drugs, and they have all felt that addiction to prescription medications is far worse than their own forms of addiction. If we can bring it into the open and let it be seen as no better or worse than any other addiction, we may be able to make some progress.

cindy muggli
first care hospice
fosston, mn

Monday, December 12, 2005

Medical Paternalism

In response to the posting What are Doctors For, the below comes in from Paul Hofmann, friend, colleague, consultant, and recognized guru in the field of medical ethics.

In conducting ethics rounds, I continue to see lamentable evidence that medical paternalism is alive and well. Too often, physicians assume their values are shared by patients and/or their surrogate decision-makers. And in some cases, when physicians have determined their values are not shared, they use their professional leverage to impose them on the patient. The basic ethical principle of autonomy is being violated when a patient "consents" to an invasive diagnostic or therapeutic procedure under these circumstances. For example, there are still physicians who insist on aggressive therapy for terminally ill patients despite their preference to the contrary. I am also aware of physicians who have written no code orders without speaking to patients or their surrogates. What is needed here is not unquestioning deference to the physician's legitimate authority nor the patient's legitimate right of self-determination. Instead, we should encourage a process that permits and facilitates an informed discussion of the patient's values and preferences. A physician colleague once told me that most doctors think communication happens when they're talking. Yes, remarkable advances in science and technology have occurred, but unless patients voluntarily and explicitly choose to have physicians make decisions on their behalf, patients should indeed be encouraged to ask the types of questions that permit them to be active rather than passive participants in the diagnostic and therapeutic process.

Tuesday, December 06, 2005

Power without Accountability

The December 5, 2005 issue of The Boston Globe carried an article by medical reporter Scott Allen about a Dr. Michael Brown and the Drug Monitoring Program operated by the Massachusetts Department of Public Health.

Dr. Brown was arrested last fall for over-prescribing highly addictive drugs including, notably, the pain killer OxyContin.

The article dealt with the question of whether the Drug Monitoring Program was sufficiently aggressive in spotting inappropriate prescribing patterns and reporting them to the proper regulatory authorities.

What I read into it was the ineffectiveness of government regulation as a means of supervising medical practice. Dr. Brown had been under suspicion for about ten years. A formal complaint against him had been lodged with the Board of Registration in 1999, but the complainant was a drug addict and Brown denied the charges. The Board was unable to resolve it and disposed of the matter by making an entry in the doctor’s file. A mothers’ group had picketed his office last summer. Not until he was actually arrested was his medical license suspended.

I think that reporter Allen put his finger on the core of the problem when, early in the article, he referred to Dr. Brown as “an internist working alone in Sandwich.”

People who have the power to significantly affect other people’s lives ought to be accountable to bosses who are responsible for supervising their performance and for taking appropriate action when performance falls short of the mark. We don’t require that in the case of medicine. We ought to.

Monday, December 05, 2005

What Are Doctors For?

We spent the Thanksgiving weekend with friends in Ottawa, Ontario where, on the Sunday, we attended St. Andrew’s Presbyterian Church.

After the service, I glanced at a rack of brochures and spotted one titled “In and Out of the Hospital.” It was published by The Council on Aging of Ottawa. Its stated purpose was “to prepare you for a stay in hospital and your return home.” The introductory paragraph stated that “You….have the right to ask questions, to get answers, and to decide what is the best action to take for your health and well being.”

Suggested questions included: Why do I need [the recommended treatment]? How much better will it make me? What are the possible complications? What are the possible side effects of the medications? What will happen if I don’t do it? Or if I wait? What alternative treatments are there?

According to my indoctrination into health care, the role of physicians was one of making diagnostic and therapeutic judgments that had life and death consequences for patients.

But if science and technology have made diagnosis more scientific and less dependent on judgment, and if in therapeutic matters patients are going to “decide what is the best action to take for [their] health and well being,” what are doctors for?

That question may sound ridiculous, but I submit that it deserves attention and may have an important bearing on the redesign of our health care system.

Saturday, December 03, 2005

Support for EBM

David Jenkins, long-time friend, former fellow parishioner, and career psychology/public health academic – now retired – offers the following in support of Evidence-Based Medicine

Evidence-based care is in a stronger position than one contributor believes. The last 20 years has seen refined work on developing and using measures of health-related quality of life. Psychometrically developed scales can be used to make reliable and reasonably valid quantification of such variables as performance of activities of daily living, anger, depression, optimism, social participation, extent of self-care, categories of mental function, social networks, and a hundred more. All these can help quantify the outcomes of medical care or the lack thereof. Our research group at Boston University assessed the benefits of major cardiac surgery in terms of emotions, cognitive processing, occupational skills, physical activity, neurological functions, social interaction, and biomedical variables.(C. D. Jenkins et al. Physical, psychological, social and economic outcomes six-months after coronary bypass surgery. JAMA 250: 782-788;; 1983).

The MAPI Institute (Lyon, France) provides a library of quality of life measures equivalently translated in many languages, thus permitting standardized indices for international studies. (www.mapi-institute.com) Different scales have been developed to assess the effect of different diseases.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com