When physicians and health care administrators talk about about "improving patient safety," they're usually referring to preventable events that occur in hospitals: blood transfusion mismatches, or infections in intensive care units, to give examples. But the vast majority of health care takes place in communities, in outpatient or ambulatory care settings ("ambulatory" being something of a misnomer, since wheelchair-bound patients can and do seek treatment in offices). In this setting, errors in dosing prescription and over-the-counter medications are an important safety issue.
Taking doses that are too large, or taking correct doses too frequently, can cause serious and even fatal side effects. An advisory committee to the Food and Drug Administration recently voted to lower the maximum daily dose of Tylenol due to evidence that many adults sustain liver damage by inadvertently taking too much. On the other hand, inadequate dosing of medications can result in conditions such as epilepsy, diabetes, and high blood pressure being poorly controlled.
Patients may take medicines improperly because their doctor gives inadequate oral or written instructions. More prescription medications also may make errors more likely. In a 2006 study published in the Annals of Internal Medicine, Dr. Terry Davis and colleagues examined the relationship between literacy levels and a patient's understanding of common prescription drug labels.
In this study, 395 English-speaking adults were recruited from 3 primary care clinics' waiting rooms. They were shown 5 labeled prescription medicine bottles and asked to describe how they would take each medication, including the number of pills to be taken in a day. The interview concluded with a health literacy assessment to determine the patient's literacy level: low (sixth grade and lower), marginal (seventh to eighth grade), or adequate (ninth grade and higher).
Out of 1,975 responses, 374 were incorrect. Most incorrect responses were dosage errors (51.8 percent) and dose frequency errors (28.2 percent). A few patients were unable to find the instructions on the label (5.8 percent) or admitted to being unable to read (3.2 percent). Incorrect responses were strongly associated with low and marginal literacy levels, and the risk of an incorrect response increased with more medications used. Surprisingly, many patients who read the instructions correctly still counted out an incorrect number of pills.
This study reinforced my longstanding (but unfortunately time-consuming) practice of asking all of my patients who take regular medications to bring in their pill bottles at every visit so we can go over how to take each one properly. Quite often, I'd find that another doctor had added or changed a prescription without telling me about it, often leading the patient to take two different medicines for the same condition. Without a single physician coordinating care, medication errors become almost inevitable. So how might health reform address this problem? Stay tuned.
Thursday, 8 October 2009
Monday, 5 October 2009
Why "patient centered" health care isn't the norm
If you aren't very familiar with medicine or have had few encounters with the U.S. health system, you may think that the concept of health care being "patient centered" is so incredibly obvious that it shouldn't need to be stated. After all, we wouldn't need health care if people didn't get sick, and the ultimate role of doctors, nurses, hospitals, clinics, and medical technologies is to either prevent patients from getting sick or to help them get well. Yet the term "patient centered" is actually a surprisingly new idea in a complex health care system that has long focused on treating discrete diseases and organ systems (e.g. the heart, the lungs, the kidneys, etc.) rather than whole patients.
When I did my medical training a decade ago, it often seemed to me that medical students were encouraged to depersonalize patients and not listen to their concerns. During my surgical and medical rotations, a patient with stomach pain became "the abdomen in room 6," and the patient with a rare or difficult-to-diagnose illness became a "great case." There was a distinct pecking order within the prestigious academic hospitals where I did my clinical rotations - attending physicians at the top, followed by fellows, residents, nurses, students and other trainees, and finally, at the very bottom, the patients themselves. We took for granted that on the basis of years of studying medicine, we knew what was best for patients, and the few who questioned whether our care was actually making their health better were quickly labeled as "difficult" or "non-compliant."
National patient safety advocate Sorrel King, whose one-year old daughter died in Johns Hopkins Children's Center due to preventable medical errors, writes in her poignant 2009 memoir Josie's Story that being in awe of the technical skills of her daughter's physicians made her reluctant to challenge questionable medical decisions until it was too late. One of the reforms that she and her foundation have encouraged hospitals to adopt is the development of rapid response teams that could be triggered by anyone in the medical hierarchy who had concerns about a patient's condition, including - and especially - patients and family members.
But you don't have to set foot inside a hospital to know that we have a long way to go to get to patient centered care. It's typical in most parts of the U.S. to have to wait months to consult a family doctor about a non-acute problem. When you finally arrive at the office, you often aren't ushered back to an examining room until half an hour or more after your scheduled appointment time, then have to wait some more to actually see the doctor, who may spend five minutes or less with you before he or she is racing off to the next patient. (I'm happy to say that not every practice I've worked at fits this description - for an example of how electronic medical records and "advanced access" scheduling can greatly reduce such inconveniences, see the website of the one of the premier primary care practices in the DC Metro area.)
In future posts, I'll write more about a few important topics that I've only touched on here: improving patient safety, shared decision making, and practice transformation, including the patient centered (there's that term again!) medical home.
When I did my medical training a decade ago, it often seemed to me that medical students were encouraged to depersonalize patients and not listen to their concerns. During my surgical and medical rotations, a patient with stomach pain became "the abdomen in room 6," and the patient with a rare or difficult-to-diagnose illness became a "great case." There was a distinct pecking order within the prestigious academic hospitals where I did my clinical rotations - attending physicians at the top, followed by fellows, residents, nurses, students and other trainees, and finally, at the very bottom, the patients themselves. We took for granted that on the basis of years of studying medicine, we knew what was best for patients, and the few who questioned whether our care was actually making their health better were quickly labeled as "difficult" or "non-compliant."
National patient safety advocate Sorrel King, whose one-year old daughter died in Johns Hopkins Children's Center due to preventable medical errors, writes in her poignant 2009 memoir Josie's Story that being in awe of the technical skills of her daughter's physicians made her reluctant to challenge questionable medical decisions until it was too late. One of the reforms that she and her foundation have encouraged hospitals to adopt is the development of rapid response teams that could be triggered by anyone in the medical hierarchy who had concerns about a patient's condition, including - and especially - patients and family members.
But you don't have to set foot inside a hospital to know that we have a long way to go to get to patient centered care. It's typical in most parts of the U.S. to have to wait months to consult a family doctor about a non-acute problem. When you finally arrive at the office, you often aren't ushered back to an examining room until half an hour or more after your scheduled appointment time, then have to wait some more to actually see the doctor, who may spend five minutes or less with you before he or she is racing off to the next patient. (I'm happy to say that not every practice I've worked at fits this description - for an example of how electronic medical records and "advanced access" scheduling can greatly reduce such inconveniences, see the website of the one of the premier primary care practices in the DC Metro area.)
In future posts, I'll write more about a few important topics that I've only touched on here: improving patient safety, shared decision making, and practice transformation, including the patient centered (there's that term again!) medical home.
Thursday, 1 October 2009
Taking the Pulse of primary care medicine
Previous posts may have implied that restoring an adequate supply of U.S. primary care physicians is all about money - that is, less student loan debt and reducing the salary disparity between "front-line" clinicians and subspecialists. If only it were that simple! Alas, even if student loans were forgiven and salaries were doubled, it is unlikely that students would immediately flock to family medicine, pediatrics, and general internal medicine. The reason: time - or more precisely, a lack of it.
Paul Gross, MD, an academic family physician at Montefiore Medical Center in New York and editor of the online magazine Pulse: voices from the heart of medicine, recently wrote a poignant piece about the challenges of family doctoring in the context of 15-minute (or shorter) appointment slots. In "Late Again," Dr. Gross observes:
"The joy of primary care is also its curse. With each patient, I have to keep track of everything--the trivial and life-threatening, the physical and mental, the acute, the chronic and the preventive. And try as I might, I simply don't have enough time. ... My colleagues and I are often still seeing our morning patients at 1:00, when our afternoon session is supposed to begin. Lunch hour? Wouldn't it be nice. And I have it easy. One hears of offices scheduling patients every ten minutes--every ten minutes!--and doctors "seeing" fifty patients a day.
Doctors talk of running on a hamster wheel. Patients complain that their doctors seem distracted, don't take the time to listen, and run late--as I routinely do. Am I a bad doctor--disorganized and inefficient? Or maybe I'm doomed to fall short as I bump up against powerful economic forces--the 'do-more-with-less' pressures that make medical administrators everywhere create schedules like mine, designed to bring in enough money to keep health centers afloat but which end up hustling me and my patients along at an impossible pace. As a nation, we are now trying to fix our foundering healthcare system. Before we set new rules in place, shouldn't we first ask this basic question: how much time is actually required to see a patient?"
As all physicians know, time spent with patients doesn't include time spent documenting visits, reviewing test results, making referrals, filling out administrative paperwork, et cetera. A 2007 study in the Annals of Internal Medicine estimated that doctors in an academic geriatric practice who saw only 14 patients per day (most docs in private practice see 30 to 40) spent nearly 8 hours per week on these non-reimbursed tasks. This reality has led some solo family physicians to adopt a no-frills practice model that relies on few (or no) staff, leading to lower overhead costs and more time to see patients. Unfortunately, more time per patient means fewer patients per day, so such a model applied nationwide would require training even more family physicians, in addition to the ones we already don't have.
Paul Gross, MD, an academic family physician at Montefiore Medical Center in New York and editor of the online magazine Pulse: voices from the heart of medicine, recently wrote a poignant piece about the challenges of family doctoring in the context of 15-minute (or shorter) appointment slots. In "Late Again," Dr. Gross observes:
"The joy of primary care is also its curse. With each patient, I have to keep track of everything--the trivial and life-threatening, the physical and mental, the acute, the chronic and the preventive. And try as I might, I simply don't have enough time. ... My colleagues and I are often still seeing our morning patients at 1:00, when our afternoon session is supposed to begin. Lunch hour? Wouldn't it be nice. And I have it easy. One hears of offices scheduling patients every ten minutes--every ten minutes!--and doctors "seeing" fifty patients a day.
Doctors talk of running on a hamster wheel. Patients complain that their doctors seem distracted, don't take the time to listen, and run late--as I routinely do. Am I a bad doctor--disorganized and inefficient? Or maybe I'm doomed to fall short as I bump up against powerful economic forces--the 'do-more-with-less' pressures that make medical administrators everywhere create schedules like mine, designed to bring in enough money to keep health centers afloat but which end up hustling me and my patients along at an impossible pace. As a nation, we are now trying to fix our foundering healthcare system. Before we set new rules in place, shouldn't we first ask this basic question: how much time is actually required to see a patient?"
As all physicians know, time spent with patients doesn't include time spent documenting visits, reviewing test results, making referrals, filling out administrative paperwork, et cetera. A 2007 study in the Annals of Internal Medicine estimated that doctors in an academic geriatric practice who saw only 14 patients per day (most docs in private practice see 30 to 40) spent nearly 8 hours per week on these non-reimbursed tasks. This reality has led some solo family physicians to adopt a no-frills practice model that relies on few (or no) staff, leading to lower overhead costs and more time to see patients. Unfortunately, more time per patient means fewer patients per day, so such a model applied nationwide would require training even more family physicians, in addition to the ones we already don't have.
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