Breaking News! Medical Students Shadowing Nurses

I just received this message from one of our Deans of Medical Education. Even though I have my first anatomy practical today, perhaps this is a sign that despite all of that, today will be a wonderful day!

Subject: New Required Educational Experience - Nurse Shadowing in M1 Year

Date: Sep 25, 2009 9:52 am

Message:

Dear M1 Class:

This year we are offering you a new required educational experience to complete during your M1 Year. You will each spend one half-day shadowing a nurse in the UM Health System.

Today’s health care delivery system challenges all health care professionals to provide care that is patient-centered, efficient, effective, safe, and timely. To meet this challenge, collaboration among members of health care teams (including, but certainly not limited to, physician and nurses) is vital. In at attempt to educate medical students on the role of nurses in the health care team as well as to foster open communication and teamwork between health professionals, this shadowing program – created originally by medical students – was run as a pilot last academic year. We hope that you enjoy the program as much as students last year did, and take something away that you can use for the rest of your careers as physicians.

We developed the following learning outcomes for the experience:

* Knowledge of what nurses bring to a health care team
* Ability to communicate effectively with a nurse
* Respect for the knowledge and skills of nurses
* Openness to learning about patient care from nurses

We will be asking you to complete a pre and a post-assessment of this experience. The post-assessment will serve as your documentation of completion of the required experience.

Sincerely,
Casey White, Ph.D., Assistant Dean for Medical Education

Little things like this that remind me why I decided to come to Michigan for med school! Do y'all have programs like this in your schools?

Quality Improvement in Baucus's Bill!

There is a lot to complain about in Senator Baucus’s health care bill, unveiled yesterday, and pretty much every stakeholder, editorialist and lawmaker has pointed out its flaws. I count myself among the disappointed—Baucus has come out with a bill that is rife with compromises, without managing any bipartisan support that would justify them. Still, I don’t want to add to the cacophony of complaints. There are, in fact, bright spots in this bill that relate to health care quality improvement. A section of the bill is devoted to improving the health care delivery system through reforms to Medicare’s payment structure. You can read the full Mark here, but if reading several hundred pages of legal jargon sounds as unappealing to you as it does to me, I’d recommend this summary, provided by the Baucus office.

The bill provides for greater coverage of preventative care under Medicare, including providing a free yearly visit with a primary care physician for every beneficiary. There is some limited recognition of a primary care physician shortage. The bill will give PCPs a 10% Medicare payment bonus for five years.

The summary notes that a fee-for-service payment system is part of the problem, incentivizing more, not better, care. So, Baucus proposes various “value-based purchasing” schemes for Medicare to test. Under the hospital scheme, “a percentage of hospital payment would be tied to hospital performance on quality measures related to common and high‐cost conditions, such as cardiac, surgical and pneumonia care.”

There are also measures to promote greater coordination of care. It would “establish an Innovation Center at the Centers for Medicare & Medicaid Services (CMS) that would have the authority to test new patient‐centered payment models that encourage evidence‐based, coordinated care. Payment reforms that are shown to improve quality and reduce costs could be expanded throughout the Medicare program.” It also directs CMS to track hospital readmission rates, and provides for financial rewards for those hospitals that keep readmissions low.

These measures are steps in the right direction—baby steps, perhaps, but they have legs. If CMS takes up the challenge they are being handed, and implements real quality metrics, this out-of-the-spotlight section of the bill could end up being incredibly significant. However, I do worry that these provisions may not be “safe” as the next round of negotiations go forward. They are threatened by rumors and fear mongering (we saw how end-of-life care counseling turned into “death panels”), and they are threatened by lawmakers who do not understand their importance. Baucus will have to demonstrate that these provisions are worth their costs; otherwise, they may not make it to the president’s desk. Let’s hope they do.

Obama's Reclamation of Health Care

Wednesday night, President Obama announced a health care plan that will provide greater security to health insurance consumers and, hopefully, control costs and improve the quality of American’s care. I, for one, thought the speech was remarkably well done – and I had very high standards for such an important speech.

But before I delve into the speech, I ought to introduce myself, as the newest contributor to the IHI Open School Blog. I’m a few months out of college and a few weeks into a one-year position here at IHI. My main interest in health care is about policy and politics, so my posts will follow the health care reform debate, as it relates to all of us who are working to improve the quality of the health care system and its delivery. Just as a note, I know my opinions can be rather assertive, so I want to be clear that I am writing for myself, as myself, not on behalf of IHI as an organization.

I’m starting from a few core assumptions. First, I assume health care is a human right. That means that any reform will be unacceptable to me if it does not achieve universal coverage. It also means that reform will be unacceptable if it leaves people “underinsured.” According to 2007 data from the Commonwealth Fund, about 25 million adult Americans are underinsured—their insurance fails to cover medical costs when tested by unforeseen diagnoses or accidents. Health insurance reform means making insurance more dependable, affordable, and transparent for all. Otherwise, health care is not a right but a luxury.

My second assumption is that government is not evil. Reform will go nowhere if any steps the government take are described as a Kafkaesque “government take-over.” Let’s be real, this is America…someone will always be there to make a profit from your pain. The reality is, government policy can change the incentives that doctors and hospitals face. The government can make it worth a doctor’s time to counsel patients on the medical decisions they must make. Government policy can reverse the perverse incentives that reward hospitals for expensive care. Most important, the government is the only publicly accountable body that can make such changes.

My third assumption is not really an assumption, but in fact a challenge to a commonly held one: that the free market is the answer to health care. A purely free market for health care would in fact be catastrophic. I’ll defer to Paul Krugman on this one (as I’m sure I’ll do on a lot of these posts):

There are two strongly distinctive aspects of health care. One is that you don’t know when or whether you’ll need care — but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor’s office; and very, very few people can afford to pay major medical costs out of pocket. This tells you right away that health care can’t be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy…The second thing about health care is that it’s complicated, and you can’t rely on experience or comparison shopping. (“I hear they’ve got a real deal on stents over at St. Mary’s!”) (http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/)

Getting back to the President’s speech, I really was very impressed that Obama rose to the challenge. He didn’t sound technocratic or boring, but he wasn’t vague or noncommittal on details either. He convinced me that the public option is not the crux of reform, and that it shouldn’t overshadow other critical consumer protections built into the law. He also chose some really great analogies to explain himself – I particularly liked how he said that a public option would provide greater choice and competition, just as public universities provide greater choice for and competition against private ones. You can read the full text here.

Some of the Republican’s reactions, though, absolutely disgusted me. I found myself screaming at the screen when Obama debunked the “death panels” lie, only for Republicans to remain seated as the rest of the audience jumped to its feet. It would have been consolation that their presence in the chamber was small--pushed to the back while Democrats took up more space than I’d ever seen--if I didn’t know that it was Democrats who have kept this reform from going forward in the past few months.

I loved the section to seniors, on Medicare: “So don't pay attention to those scary stories about how your benefits will be cut, especially since some of the same folks who are spreading these tall tales have fought against Medicare in the past and just this year supported a budget that would essentially have turned Medicare into a privatized voucher program. That will not happen on my watch. I will protect Medicare.” Another moment of uncomfortable Republican seatedness. And I loved the attempt to shame Congress for their inaction: “ We did not come to fear the future. We came here to shape it.”

Whether this speech can make a difference remains to be seen. I hope it can, and I’ll be watching closely to see.

My First Patient

As I put on my first set of scrubs before entering the anatomy labs for my first dissection, I realized that I have never really examined my own body very closely.

However, this realization does not mean that I've never tried. The scars on my body are a road map to all of the ways that I have tried to figure out what lies beneath my skin. For example, I have a scar on my tongue from stapling it and messily extracting the staple on my own when I was six years old. My mom had just had surgery and I couldn't understand why she had staples across her belly. Weeks later, after I was told that doctors use instruments that look a little like kitchen knives to open and fix the body, I sliced my finger with the pizza cutter. Burning my cheek with my mom's curling iron not too long after the pizza cutter incident was the last straw. My parents very wisely remembered to add "don't try this" to any of their stories that could be interpreted as a new way to "test" something on myself. What I must have innately understood is that there is no better way to learn than to learn by doing.

With this dangerous streak of curiosity in me, I was surprised to find myself, 17 years later, walking with trepidation down the corridor towards the anatomy labs. The ultimate chance to learn was finally here. But, my steps had lost their usual spring (not just because my scrubs were too big) and rather than looking straight ahead, the scuff marks on the ground began to "fascinate" me. I couldn't contain myself when I thought about finally peeling away the skin to see how all of the different parts of our body worked together. Anatomy has a tangible tie to the practice of medicine, much more than sitting in a lecture hall learning about protein structure. So, what was I waiting for?

It wasn't the smell, the fear of cutting, becoming intimate with death, or even the overwhelming amount of material that was soon expected to become second nature to us. I was afraid of this gift: a complete stranger and her family have given me the opportunity to examine a body and know it far better than my own. The cadaver I was to spend the next few months with was not just going to be my teacher, but also my first patient. However, unlike my future patients, I will never know anything about her life except for what I can infer from her road map of scars. Her stories will remain a mystery. She has allowed me to crack open her spine, poke through her muscles, dig deep to find bundles of nerves--all things that she herself will never have the privilege of doing. Yet, her laugh, her voice, and the sparkle in her eyes are not even things that I can imagine and ascribe to her.

Perhaps it is this asymmetry of information that makes our relationship unique.While these missing pieces make it easier to objectively and academically canvass her body and focus on the science of the human body, I find myself inserting a piece of me into every gap of knowledge. For every incision I make and for every intricacy I am able to uncover, I am mentally making the same incision and discovery in myself. Her spinous processes are now also my spinous processes. Even though I have the exhilarating chance to remove each piece and uncover the delicate spinal cord, I must respect and care for each piece as if it were my own. I do my best to be attentive just in case I'm lucky enough to illuminate a precious pearl about her life.

After understanding and appreciating this special relationship with my first patient, I walk into anatomy lab with a sense of humbleness to accompany my geeky excitement. In anatomy, we are learning by doing. We are learning and practicing how to listen and learn from our patients by doing just that.

There really is no better way to learn.

The System- In the Patient's Words

The following is written by a parent of a child with special healthcare needs. I was given permission by this parent to publish her story on this blog (after de-identifying the family). The story illustrates the importance of the system in which care is provided. It seems more and more apparent to me that we can be the best providers we can be, but if the system doesn't work for our patients and their families, we won't achieve desired outcomes (and our families will continue to suffer the consequences). Yet another reason that IHI's patient-centered approach is so important!

My name is Jaclyn and I have been a lifelong resident of Connecticut and I’m a parent raising a special needs child. My daughter was born prematurely at UCONN Medical. In October 2003 my daughter was diagnosed with Cerebral Palsy and is currently wheelchair bound. For me, January 14th 2009 makes 6 years of being unemployed.

My daughter is totally dependent on me to carry her up and down the stairs for her baths and to be put to bed and to get her ready for school and other activities. She attends kindergarten and being that I don’t have ramps at either front or back doors, I have to roll her down the steps to get her on the bus. Her movements are so sporadic, I often will have random bruises such as a swollen lip from her hitting me in my face. I use to receive home health aid assistance 40 hrs a week and those were cut to 10 hrs a week, which is not efficient help for me caring for her. I don’t have any choices but to financially depend on state assistance and the disability I collect for my daughter. Although, under valid circumstances, I often feel degraded by the DSS workers. I have called nearly every daycare center/childcare provider in and around my town only to be told my daughter doesn’t qualify for daycare because she is a liability, she’s not potty trained or there is no qualified staff to take care of children like mine. I have called the senator who services my district, the mayor, the board of education, the United Way and spoke with the principle at her school to ask for help in finding a qualified daycare that will accept her. Those leads did not pan out and I finally given up when a coordinator at 211 info line explained to me that Connecticut doesn’t have daycares for special needs children.

I never wanted to quit my job but it was a disheartening sacrifice I had to make. If it were possible for me to work, I wouldn’t have anyone to place her on the bus or have anyone to receive her after school. The easy part is to go to work during the hours she is in school but quite often the school calls me to come pick her up because she may have had an accident or she’s not feeling well enough to stay. I also have to consider weather delays, shut downs, early dismissals and even her summer vacation.

Bottom line, I have virtually no assistance for my daughter or myself. My mother is the only one who will pitch in when she can but she is 64 years old and still working for herself. Placing my daughter in a group home would literally kill me. I love her more than I love myself and will fight and sacrifice for her till my last day.

Study: Surgeon Experience Doesn’t Impact Patient Deaths

Here's some evidence of the importance of care teams to improve care rather than the work and effort of individual heroes that I found on the WSJ Health Blog. How would the system of care change if the team of trauma surgeons was expanded to include all members of the surgical team (anesthesiologists, nurses, etc.)?

Whether a trauma surgeon is a novice or experienced makes no difference on patients’ likelihood of survival, according to a recent study published in the Archives of Surgery. Instead, it appears that the overall system of care is more important.

We caught up with Elliott Haut, first author of the study and an assistant professor of surgery at Johns Hopkins, to discuss his findings. Here is an edited excerpt of the conversation.

Surgeons’ years of experience didn’t have an impact on patient mortality. Why is that?

I think there probably are very specific cases where very experienced surgeons do make a difference. But when you look at it as a whole — thousands and thousands of patients treated by different kinds of surgeons — it’s the system that makes the difference.

It doesn’t put [a veteran surgeon] out of a job. You need an experienced person to set up the system. It just means that we as a group of trauma surgeons need to have a system in place to treat all the patients in the same way, with evidence-based guidelines.



What defines the “structured program” that seems to be so important to patient outcomes?

At Johns Hopkins, we have a trauma attending surgeon. They’re going to show up with full team of residents. We have dozens of algorithms in our trauma manual that are given to our trauma residents. It helps guide you through some of the simpler things.

That senior, experienced trauma surgeon is an excellent mentor for junior people. We meet [as a trauma team] every morning at 7 a.m. We review every single trauma patient, go over what happened to them, what tests were done, vital signs, if the patient had surgery, what operation it was. It’s the real-time judgment and mentoring. All these pieces play a role; it’s not clear what’s the most important.

Simple Observations...

Below are some observations made by a fourth year med student while on her sub-internship at a different hospital. Just think how far redesigns like communication tools, dept location, and a different culture can go to improve patient care and the patient experience! I'd be interested to see any outcomes data on some of these changes!

The lessons from one of the best hospitals in the world...: During the past month at MGH, arguably one of the best hospitals in the US, if not the world, I looked for subtle, innovative ideas that outsiders might not notice from simply taking a brief tour around the hospital. Health care is a complicated beast, and it really was the little things that made a big difference, not the obvious surgical robots or shiny buildings that meet the eyes of visitors.

1. The Get-to-know-me chart
In the room of every patient who cannot communicate for various reasons (stroke, delirium, intubation, whatever prevents a person from communicating), there was a Get-to-know-me chart, which consists of:
- Name AND 'Likes to be called'
- Important people in my life
- Favorites
- At home I use (patients check all that apply): glasses, contacts, hearing aids, dentures
- I understand information best when...
- Achievements
- Things that stress me
- Things that cheer me up
- Others
Some of these charts are filled by the patient before surgery expecting that they might not be able to communicate post-op. Others are filled by their family members. We can imagine how important these answers are when a patient is unable to communicate well with their providers, when they may only be conscious enough to respond to the names they are called everyday, when their world tumbles in times of sickness and the important people in their lives or things that usually cheer them up can make a huge difference, when they are thrown into a new environment and things you usually rely on to function (like hearing aids, glasses) are taken away.

2. The ED observation unit
It is the limbo between the ED and the floor. Many times ED patients await beds or lab results to determine whether they need to be admitted, at which time they no longer need the specific sets of skills and services from the ED staff. The ED observation unit houses these patients so that the ED can triage new patients that need urgent care.

3. Radiology consult
Any physician in the hospital can walk into radiology reading rooms (all of which are located in the same area: neuroradiology, CT, MRI) to review imaging of their patients with a radiologists in person, in order to ask field-specific questions that are usually not answered by the broad comments in the final read. Every time we walk in, the radiologists say with a smile, 'How can we help you?,' as if they were greeting customers. It is definitely a far cry from Elmhurst hospital, where you can't get a hold of radiologists at whom you need to yell and argue to have them approve the study that you want. Asking them for a personal imaging review would be asking for insults coming your way.

4. Location, location, location
At MGH, all microbiology labs (virology, parasitology, etc) are grouped together, next to the Infectious Disease offices and team rooms, and that is no accident. Whenever a test result is positive, the teams walk down the hall to review lab findings in person, ask questions and get rapid updates as soon as a culture turns positive. A neurosurgery ward is across the hall from the neuro SICU - crashing neurosurgical patients can be rapidly whisked across the hall to be stabilized in the ICU. The CCU is next to the cardiac step down unit - cardiac patients can move rapidly between the two units depending on their cardiac status.

5. The Bigelow service
In most hospitals, interns on a team split patients - one intern does not know anything (or care) about another intern's patients. On the Bigelow service, all the interns share all the patients on the floor. This requires the interns to communicate among themselves regarding all development and treatment choices for each patient. It fosters a foreign concept of teaching physicians to work together and communicate with one another regarding a shared patient, which above the intern level actually happens everyday and everywhere. It also makes sense that an intern knows all the patients on the floor, since all of them are only cared for by one intern on call each night.

6. Communication
On the consult service, I learned to uphold utmost politeness in communicating with other doctors. At the end of every consult we write - thank you for this interesting consult, we will follow along with you. We also make it a point to always communicate recommendations verbally to the primary team, ON TOP OF recommendations written in the chart. At Sinai, I inched gingerly up to the consulting team and before I could ask a question, their first comment was whether I had read the chart, as if we were meant to talk to one another through pieces of paper deprived of personal cues that enhance our grasp of a message.

7. The staff
Most of the hospital staff (nurses, in particular) were there for the grind to earn money - many took no interest in the medicine or in their patients. They clock out right at the end of their shift. Many refuse to do anything other than the required lab draws and vital checks - they refuse to assist others looking for information on the status of their patients, which arguably nurses know best. Others do not care to learn what the patient has and what treatments are coming their way. None of this is true at MGH - nurses ask to be present when doctors explain treatment plans to patients. They suggest care alternatives that improve patient outcomes or reduce costs.

MGH may have flaws that plague other hospitals across the nation (commercial-driven hospital policy, budget cuts in times of depression), but it has merits that sure make for a special place for the lucky patients that can afford it.