So many gaps, so little time.... That would be a ready conclusion from the extensive body of literature on gaps in patient care, medical errors, and patient safety. A recently released in-depth report from the American Medical Association, Research in Ambulatory Patient Safety, chronicles gaps related to diagnostic, laboratory, clinical knowledge, communication, and administrative (potential) errors. The possible combinations among these five domains is extensive.
The following paragraph is from the American College of Physicians Ethics Manual, 6th Edition:
“Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians' considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches. When patients ask, they should be informed of the rationale that underlies the physician's recommendation.“
With synonyms for parsimonious that include miserly, stingy, and frugal, it is no surprise that this word choice evoked some criticism. The preponderance of the Ethics Manual advocates that the physician’s primary obligations and duties are to the patient, exercising beneficence, confidentiality, and honesty, with the best interest of the patient being paramount. The paragraph above is a small, but important, segment of the Ethics Manual.
A visit to my dental hygienist this week began with a conversation about diagnostic tests. Before the dental x-rays, I asked Dottie if I needed x-rays, and she replied that it had been 18 months, and, based on my age and past dental history, every year to two years was a reasonable interval. Not wanting to debate this point before confronting the Cavitron, I accepted that rationale.
This post is not about coronary artery disease. Nor is it about the “stiff” ventricles in diastolic heart failure.
Like “Never Rest”, which I posted several weeks ago, this brief discussion was inspired by Saturday morning Torah study. “Harden Heart” refers to the Pharaoh at the time of Moses and the Exodus from Egyptian slavery. What struck me from our discussion on Saturday morning that relates to health plans and health benefits is that those of us who have responsibility/authority over what is reimbursed, or not, how it is reimbursed, and at what level are — metaphorically — in a parallel role to the Higher Power in the Torah passage. Those whom the purchasers and payers are influencing, or who are on the receiving end of attempts at influence by the purchaser or payer are, metaphorically, in the position of Pharaoh (No implication or suggestion intended about virtue or lack thereof on either side of this analogy!). They are employees, plan members, health care professionals and facilities, ancillary providers, and any other entities that are being paid for services.
In the story, it takes many sticks (no carrots) to ultimately influence Pharaoh to free the Jews. The question that we discussed and debated is to what degree God hardened Pharaoh’s heart and to what degree did Pharaoh, using free will, refuse to set the slaves free even in the face of punitive actions — the plagues.
After grand rounds this morning at the University Medical Center at Princeton, the director of the recently created transitional care program, Kathleen H. Seneca, MSN, was speaking with one of our nephrologists about the purpose of the program. It fills the transitional gap for people discharged from the hospital that do not qualify (in terms of reimbursement guidelines) for home care, but would benefit from additional education, care planning, and hands-on instruction.
Leaving the gym on an unseasonably warm night, I struck up a conversation in the parking lot with a vascular surgeon acquaintance. He recounted a technically demanding procedure that he had done the day before with a reported 10 percent risk of stroke and a 3 percent mortality risk.
If you thought Level 3 Medical Home, you were correct. If you thought retainer (concierge) practice, you would also be correct. To me, it seems eminently rational for people who have sufficient discretionary income to choose to use it to obtain more rapid access to a personal physician of her/ his choosing through a retainer (concierge) practice.
The drumbeat of EBM — Evidence Based Medicine — seems less vigorous in the wake of enthusiasm for new models of care — Medical Homes and Accountable Care Organizations — and reimbursement based on performance, outcomes, or episodes of care.
In my Saturday morning Torah study, we focused on Jacob’s “settling in” with his family. After years of struggle, Jacob becomes complacent, comfortable. We discussed whether Jacob’s complacency — his relative inaction — contributed to the animosity that led Joseph’s brothers to sell him into slavery and to report to their father that his then youngest son had been killed.
Mark Herzlich, Boston College All American linebacker and now New York Giants rookie, believes that positive thinking played an important part in his successful battle "to beat bone cancer" and return to football. World-renowned cyclist and cancer advocate Lance Armstrong credits not only topnotch medical care but also positive thinking in his overcoming testicular cancer. Armstrong stated on CBS Sunday Morning, "You can't deny the fact that a person with a positive and optimistic attitude does a lot better." Like the vast majority of individuals polled on whether or not the positive thinking can influence cancer outcomes, I believed/wanted to believe that positive thinking would be correlated with better survival data. But the weight of evidence does not support the thesis that optimistic attitude trumps the Big C, or even influences oncology outcomes.