The medical trivia quiz

In case no one has been looking at the calendar, it’s National Doctors’ Day today, an occasion for showing appreciation for physicians and the work they do.

How much do you know about the medical profession and its history and influence on our lives? Here’s your chance to find out. Take the HealthBeat trivia quiz and test your smarts on all things medical. Answers to the quiz will be posted here on Friday.

1. What is the origin of the word “doctor”?

2. Which of these individuals is considered the founder of medicine?  a) Galen  b) Aristotle  c) Hippocrates  d) Asclepius

3. Who or what is a caduceus?

4. What ancient language forms the root of many of the medical and anatomical terms we use today?  a) Aramaic  b) Latin  c) medieval French  d) Arabic

5. At one time, the center of medical education was in Europe. Now many of the world’s top teaching institutions are in the United States. Name the first medical school to be established in the U.S., and give yourself a bonus point if you can identify at least one other college that is among the five oldest.

6. One of the first integrated group medical practices in the world was founded by two brothers from the American Midwest. What are their names?

7. Minnesota author Sinclair Lewis wrote two memorable novels in which a doctor is one of the main characters. One of these protagonists is idealistic; the other is highly practical. Name one of them (and give yourself a bonus point if you can name both and another bonus point if you can also name at least one of the novels).

8. How much was the average educational debt for students who graduated from medical school in 2009?  a) $40,000  b) $90,000  c) $155,000  d) $250,000

9. This television show made its debut in 1969 and quickly became one of the most popular medical dramas of all time. Name the show, and receive a bonus point if you can also name the starring actor.

10. This medical specialty was unknown until the past decade and is currently growing the most rapidly. Can you name the specialty?

Image: “Laennec at the Hopital Necker, Examining a Consumptive Patient by Auscultation,” Theobold Chartran, 1816

But what about tort reform?

A lot of physicians were hoping the new health care reform bill would contain provisions for tort reform. Alas, they’ve come away from the table empty-handed; the bill offers little that’s new on this particular issue.

What it does contain, however, is some funding that will allow states to develop pilot projects that address medical liability. It’s not much money – approximately $50 million in grant money for which states can apply. And the goals are fairly narrow: The money must be used to develop alternatives to litigation that help resolve disputes over medical injuries, and/or to collect data and share it with health care organizations that focus on patient safety.

The Law Blog at the Wall Street Journal writes:

We checked in with folks from both sides of the aisle and, frankly, nobody seems all that troubled by this requirement. The trial lawyers are urging that states that apply for a grant to work on "patient safety" issues, rather than on other dispute-resolution techniques.

"We think patient safety is the way to go," Anthony Tarricone, the president of the American Association for Justice, told us in an interview. "If there’s no medical error to begin with, then there aren’t lawsuits." One example Tarricone tossed out: hand-washing programs at medical facilities to reduce infections.

It’s about time. I think this assessment is somewhat missing the boat, though, by not emphasizing the importance of alternative dispute resolution.

Few would argue that litigation is a good way to settle disagreements over who’s liable for a medical injury – and make no mistake, medical injuries can happen regardless of how many safety measures are in place. It’s grueling for the defendants, whose every decision gets raked over the coals. It’s grueling for patients and families too.

Despite the multimillion-dollar verdicts we read about in the headlines, most litigants don’t walk out of the courtroom with newly found wealth. The median range, according to this source, is $125,000 for an out-of-court settlement and $235,000 for a jury verdict. What’s more, most people injured by a medical error don’t ever sue, nor do they receive any form of compensation for their injury.

There’s also considerable debate over the extent to which runaway malpractice lawsuits are contributing to the cost of medicine. Last fall the Congressional Budget Office estimated that tort reform could save $54 billion over 10 years. Other experts believe, however, that med-mal costs have been exaggerated and that tort reform would result in negligible savings at best.

What’s been missing in the entire discussion? Two things: 1) prevention, after the fact as well as before; and 2) alternative, less stressful ways for everyone involved to make amends and fairly compensate the patient and/or family. Doug Wojcieszak, the founder of Sorry Works!, nails it with an editorial he penned last year on health care reform:

We need to shift the discussion from a political and legal fight to a focus on customer service and how to help the doctor-patient relationship transcend a medical error, and in so doing avoid costly litigation in most instances while improving quality and safety – and saving a whole lot of money in the process!

A growing body of evidence in the peer-reviewed medical literature shows that patients and families primarily file lawsuits against doctors because of anger, not greed. Patients and families become angry with their doctors (and nurses, hospitals, insurance companies, etc.) when communication, honesty, accountability and – literally – good customer service are lacking after a perceived error. In other words, patients and families are suing not so much because of errors, but because of the bad behavior surrounding errors.

It’s a whole different way of looking at the issue. It suggests that what we really need, in fact, isn’t tort reform but a more responsible, humane way altogether of dealing with injured patients. Critics can go ahead and complain that the health care legislation has done little more than throw a few table scraps in the direction of tort reform. I’m going to be optimistic that someone, somewhere, is going to have the guts to try a new approach that’s better for everyone involved and saves money besides. After all, we have nothing to lose.

A failure of transparency

The patient was planning to have her gall bladder removed. Before the procedure, she met with the surgeon to talk about the risks and the surgeon’s skill and experience with laparoscopic surgery. Among the questions the patient asked: Had the doctor ever been sued for malpractice or had sanctions against his medical license? He said no.

You’ve probably guessed where this is heading. During the surgery the patient’s intestine was perforated and she developed an infection. She later found out the surgeon was disciplined subsequent to having a patient die after undergoing the same procedure.

The woman sued, alleging malpractice and lack of informed consent. She lost. Now the case is headed for a retrial after the U.S. appellate court sided with the plaintiff’s appeal of the verdict. At the heart of the issue is whether the trial court erred in tossing out the argument that the physician’s deceit constituted a breach of the patient’s right to informed consent.

I stumbled across this fascinating legal case this week at the Shrink Rap blog, where it has generated considerable discussion. It raises some compelling questions about patients’ rights to informed consent and the extent of the information physicians should be expected to disclose. Shrink Rap wonders how far it should go:

What if the issue wasn’t technical competence? How much “personal background” should a doctor have to tell a patient before treatment can begin? Medical school grades? Failure to pay income tax? Should doctors be required to disclose to patients the fact that they’ve been treated for mental illness themselves?

Grade point average? Income taxes? I have a hard time picturing any kind of case law that would justify this level of prying. That doesn’t appear to be what this case is about, though. It seems to me that the physician’s competence and experience is highly relevant to informed consent. If this patient had known ahead of time that the surgeon was disciplined following the death of a patient – a death involving the same procedure the patient was about to undergo – it’s possible she would have chosen a different surgeon.

And outright dishonesty adds a whole new wrinkle to the case. Is it ever OK for a physician to dissemble in response to a patient’s question? One of the commenters at Shrink Rap concludes it was “moral turpitude, maybe, but not malpractice… Patients have a right to ask any question they want to ask. Doctors have a right to decline to answer, then the patient can decide how to proceed.”

Others disagreed. From one commenter: “It’s not his right to lie to the patient so they’ll sign the consent form so he can make money.” From someone else:

I disagree about it being an issue of “personal background.” Whether or not the doctor had previously lost patients from that procedure, and whether or not he had had action taken against him is professional background, not personal. “Personal” that it affects only the private life of the individual in question. Just because something could go wrong no matter how skilled the surgeon doesn’t justify lying about the outcome of prior surgeries, especially given that the patient directly asked. It wasn’t a lie of omission, it was a flat-out lie about something that the patient clearly considered important information to their decision about the surgery.

I personally think it was a smart question to ask, and one that most medical professionals shouldn’t hesitate to answer honestly.

It’s actually not that hard to find out whether a physician has a valid license or has ever had sanctions against his or her medical license. In Minnesota, the database is maintained by the Board of Medical Practice and it’s easily searchable online. I’m not sure, however, that we can assume most patients know this. The burden tends to be on consumers to either do their own homework, or to be savvy enough to ask the physician (and hope they get an honest answer).

By sheer coincidence, the Center for Public Integrity issued a report this week that takes policymakers to task for failing to make the National Practitioner Data Bank more accessible to the public. The report notes that while the public can view statistical portions of the NPDB, “the law blocks public users from pulling up histories of individual doctors or other health care professionals. Only authorized users such as hospital administrators can do that. A physician can see only his or her own record.”

Theres a complicated push-and-pull over how much information consumers/patients should have. Where should the boundaries be drawn? How much decision-making power should consumers be given? How much of this power are they capable of handling? We haven’t figured it out yet, and I think we’re going to be debating this for a long time to come. While I don’t expect the retrial of the case involving the dishonest surgeon to completely rewrite case law, perhaps it’ll add another layer of insight into how we define informed consent and what level of disclosure is due between physician and patient.

Health care reform: When all is said and done

I’ve been holding off on blogging about the passage of the health care reform bill, mainly because I wanted to wait and see whether it actually passed.

Now that it’s a done deal, the commentary is exploding across the airwaves, the newspapers and the blogosphere, as well it should. Regardless of how you feel about the final bill, it’s a historic watershed to achieve legislation of this magnitude. In some form or another, the health care reform bill will affect virtually every American.

I don’t possess the proverbial crystal ball, so it’s impossible to predict whether this legislation will ultimately help or hurt. I suspect it will fall somewhere in the middle – maybe not the solution many hoped it would be, but not the destruction of health care either.

For sure, it has aroused strong emotions among the public. For sure, the process got way too political. I’m not going to pose a debate here, however, about the details of the legislation or how it was accomplished. Instead I have some philosophical questions:

Is there any way to meaningfully address health care coverage and costs without making substantive changes? Or could we have accomplished the same thing by tinkering around the margins?

If you disagree with the legislation, what in your opinion would be the right way to address health care?

Could we have come up with legislation that the majority of Americans could agree on? If so, what would it have looked like?

What would have been the cost of doing nothing? What would have been the cost of a short-term Band-Aid solution?

The rhetoric surrounding this issue has been unreal: shrill, angry and frequently substituting opinion, speculation and outright misinformation for fact.  The fact is, there’s no painless way to fix what ails the health care system, and there’s no quick fix either. Although this new legislation is regarded in some quarters as some kind of Healthmageddon, it primarily expands access to health care coverage. It barely addresses cost and quality, which are even larger issues.

The rumblings have already started about mounting an effort to repeal the bill. If that happens, I can’t imagine what it would take to try to recraft health care legislation that might be more acceptable. Not only would it severely damage the political appetite for doing something about health care, but it also would set a precedent I’m not sure we’d want.

The ink is barely dry, folks. Many of the provisions in the bill don’t take effect until 2014. Emotions are running way too high right now. Can’t we wait and see what happens? History, after all, can’t really be judged until after the fact. I could blog a lot more but I’d rather let readers have their say. You can leave your comments below.

For some facts about the health reform legislation, there’s a good summary here. There’s also an interactive tool here that explores what the legislation means to individuals. 

Update, March 24: If you’d like to continue reading more of the analysis and public discussion about the health care reform legislation signed into law yesterday, check out the “Conversations” section at the New York Times online. At last count there were nearly 2,000 comments on the final reconciliation bill. At The Health Care Blog, there are several interesting commentaries: “What’s next with health care (and why this process was madness”; “The reinvention of social progress”; and an examination of the constitutional issues surrounding mandated health insurance. For a physician’s point of view, check out what Dr. Rob Lamberts has to say; in a nutshell, he suspects we’re merely rearranging the deck chairs on the Titanic. And here’s a look back at the milestones and game-changing moments in the health care reform debate.

Multitasking Nation

On your way to work this morning, or dropping off the kids at school or going to the store, how many of you were yakking on the phone while you drove? Maybe you were drinking coffee or, heaven help us, applying your makeup or eating breakfast. When you arrived at work you were promptly busy juggling three or four – or more – projects, checking your voice mail, checking your e-mail and surfing your favorite Web sites. As the day progressed, the work piled up, along with countless distractions and interruptions. You drag yourself home at 5 or 6 p.m., make dinner while watching TV, and divide the rest of your evening between paying your bills online, texting and checking your voice mail while doing the laundry, unloading the dishwasher, walking the dog and supervising the kids.

Welcome to Multitasking Nation, where more, more, more equals MORE. Or so we’d like to think.

Somewhere along the way, the number of tasks we can juggle at any given time seems to have become the yardstick for how successful we are at managing our lives. What we’re conveniently forgetting (or ignoring), however, is the fact that biology is stacked against us.

The human brain is a pretty amazing thing. It can process thousands of bytes of sensory input – what we see, hear, smell, taste, feel, remember – at lightning speed. Even when the brain is injured, it can adapt. But what it apparently can’t do is process multiple things simultaneously – or at least not process them with any proficiency.

The brain’s ability to multitask has been getting a lot of attention in recent years, probably because of our increasingly hurry-up lifestyle and the growing number of distractions to occupy our time. The Neurophilosophy science blog explored this issue awhile back with a good explanation for the layperson:

We know well that it is very difficult to concentrate fully on more than one task; researchers are now beginning to gain an understanding of the neural bases of the limits of multitasking (and some hope to overcome them with augmented cognition). Recent neuroimaging studies in which participants switch between one task and another have implicated several regions of the frontal cortex as bottlenecks to the processing of information. It is emerging that multitasking places excessive demands on executive control centres in the frontal lobe. Hence, multitasking is counterproductive – not only does completion of all the tasks take longer than if they were performed one at a time, but performance on all tasks is also impaired.

NPR put together an interesting series back in 2008 that took a closer look at what happens when the brain tries to multitask, and why so many of us are fooled into thinking we’re good at multitasking:

“People can’t multitask very well, and when people say they can, they’re deluding themselves,” said neuroscientist Earl Miller. And, he said, “The brain is very good at deluding itself.”

Miller, a Picower professor of neuroscience at MIT, says that for the most part, we simply can’t focus on more than one thing at a time.

What we can do, he said, is shift our focus from one thing to the next with astonishing speed.

“Switching from task to task, you think you’re actually paying attention to everything around you at the same time. But you’re actually not,” Miller said.

“You’re not paying attention to one or two things simultaneously, but switching between them very rapidly.”

Some research suggests that with cognitive training, people can become better at juggling multiple brain activities. Even with training and practice, however, it appears that task performance is generally better when the tasks are carried out independently than when they’re done simultaneously.

I’m all too familiar with the feeling you get when your synapses are overloaded. As we approached a major deadline here in the newsroom last week, a couple of colleagues remarked that their brains had turned into oatmeal. (Mine felt more like cold molasses.)

The implications of multitasking on people’s ability to function effectively are obvious – particularly so in highly cognitive fields such as health care, where the demands on one’s focus, concentration, and attention to detail and accuracy are extreme. Distractions and interruptions are significant contributing factors to medical errors. When a Minnesota surgeon accidentally removed the wrong kidney from a patient a couple of years ago, distraction and subsequent failure to note the correct surgical site in the patient’s medical record during a pre-surgery office visit were cited as among the causes.

In one study that looked at the emergency room in a large teaching hospital, registered nurses experienced an average of three interruptions per hour, usually a phone call, a page or face-to-face discussion. Even background noise can be a serious distraction to providing safe patient care, which is one reason why many hospitals are trying to create a quieter environment. When Rice Memorial Hospital built a new patient wing a few years ago, it incorporated medication rooms where a nurse or other clinician can step away from a busy nursing station and prepare a medication dose in somewhat less stressful surroundings.

Like many of the rest of us, health care professionals tend to think multitasking comes with the territory. An interesting article that appeared a few years ago in the journal of the American Association of Perioperative Nurses notes how this has been ingrained into health care culture:

… There is little opportunity to say “no” or “not now” to distractions or interruptions. There may even be an unspoken expectation that part of a health care clinician’s job is to handle all types of interruptions effectively and to do so without appearing stressed or flustered. The reality is that humans have a limited capacity to manage distractions and interruptions in a safe manner.

We’ve all heard the phrase “do more with less.” And up to a point, it’s true. But eventually the returns start to diminish and we find we’re not doing more with less, we’re just doing less. No matter how good we think we are at multitasking, we can’t outwit our own brains.

When the patient is a no-show

If you want to irritate your doctor, the nurse, the medical assistant, the receptionist and pretty much everyone else you deal with at the clinic, it’s easy: Blow off your next appointment. Don’t call ahead of time to cancel or let someone know you’re running late. Just don’t show up. Give yourself bonus points for not calling afterwards either to apologize or reschedule.

Physician clinics, dental practices, optometry centers – you name it, they’ve all struggled with the perpetual issue of no-shows. These days, however, with crowded appointment schedules and clinicians’ time at a premium, it’s becoming a bigger deal than ever. And it should come as no surprise that some area clinics are starting to crack down on patients who don’t show up.

How often do patients fail to keep a scheduled appointment? It’s not clear. Rates appear to vary from one clinic to the next. One study by the Medical Group Management Association put the national average at 5.5 percent. The one sure thing is that health care practitioners seem to almost universally regard no-shows as a problem.

In health care, time is often money. When an appointment slot is booked and the patient doesn’t show up, it’s a lost opportunity to earn revenue. Like it or not, few businesses, including health care practices, can afford to put up with a high rate of no-shows. One academic practice in Milwaukee broke it down into some rather startling numbers:

Between 2000 and 2002, the average no-show rate for our academic practice was 30 percent. We intuitively believed that a disproportionate number of missed appointments were being caused by a small group of patients. In 2002, our practice had 12,100 arrived visits and 4,438 no-shows. No-shows were defined as intended appointments that were not canceled or rescheduled at least two hours before the designated time. Each no-show patient had between one and 18 missed appointments. This accounted for more than 1,300 clinic hours.

It’s not just about the dollars and cents, though. That empty time slot could have been used by another patient who needs to see the doctor. When patients skip an appointment without calling ahead to cancel, physicians and their staff also can perceive it as disrespectful – and it’s the kind of thing that tends to tarnish the relationship.

Clinicians have tried different tactics to discourage no-shows. Some of these strategies are purely preventive: for instance, letters or phone calls to remind patients of an upcoming appointment. More stringent measures might include asking patients to pay a deposit ahead of time, charging patients a no-show fee, or putting them on probation if they miss an appointment without calling first. As a last resort, the habitual no-show offender might be fired from the physician’s practice.

Harsh and unfair? Well, I don’t know.

Measures like these appear to be entirely legal, as long as patients are informed of the policy and what’s expected of them. Enforcement should not be too draconian, advises

The implemented no-show policy should be reasonable to avoid patient complaints and the transfer of good patients to other providers. For example, a policy may state that a patient who arrives more than 30 minutes late shall be assessed the no-show fee. But, if patients are routinely required to wait 30 or minutes or more from the scheduled appointment time, the hypothetical policy is likely unreasonable.

So what about the patient’s side of the story? There are times, after all, when skipping an appointment might be unavoidable. Maybe they had a flat tire on their way to the clinic, or a last-minute household crisis. There might be cases in which someone is too sick to come to an appointment – the story of 85-year-old John Williams of South Carolina, for instance, who missed a 9 a.m. appointment with his physical therapist because he’d fallen and broken his hip.

Or do patients skip appointments because they just don’t care?

Studies have come up with some rather interesting findings. This survey, conducted at the University of Nebraska Medical Center, suggests that some patients “did not feel obligated to keep a scheduled appointment in part because they felt disrespected by the health care system. The effect of this feeling was compounded by participants’ lack of understanding of the scheduling system.”

Other research has suggested that patients who frequently skip appointments tend to be younger, lower-income and have a history of missed appointments and psychosocial problems.

Here’s a surprise, though: Medical practices might be unwittingly contributing to their no-show rate by how they handle their scheduling. That’s one of the conclusions drawn in a study published last year by the American College of Physicians, which found that the logistics of the visit, not the characteristics of the patient, were among the most important factors. When the study’s authors, who are on the faculty at the University of Missouri, analyzed 11,000 scheduled visits, they learned that Medicaid patients scheduled for an appointment after 3 p.m. almost never showed up because that was when public transportation shut down for the day.

Another finding: How the appointment was scheduled seemed to matter:

Schedulers with higher proportions of no-shows were following practice protocol and scheduling the first caller for Monday at 8 a.m., the second for Monday at 8:30, etc. More successful schedulers, however, started the conversation by asking patients, “When would you like to come in?”

Whether the patient had to travel for the appointment also appeared to be a factor:

The study revealed patients who lived five to 10 miles from the practice were very likely to show, while those who lived between 19 and 60 miles were more likely to miss their appointments, but anyone coming from more than 60 miles away almost always showed up.

Other studies have suggested that long waits between the time the appointment is scheduled and the actual date of the appointment tend to increase the likelihood of a no-show.

For what it’s worth, I think it’s disrespectful of patients to fail to show up for an appointment without calling first and cancelling, so their slot can be offered to someone else. I can’t really blame medical clinics for wanting to crack down on this behavior. But before booting the patient to the curb, medical practices ought to ask themselves: What’s the real reason this person is skipping appointments and what can we do that might be helpful? Solving the issue of no-show patients might be more of a two-way street than we think.

The shock of the new

Orphaned by civil war in Sudan, John Bul Dau, Daniel Abol Pach and Panther Bior left behind everything that was familiar. The drive to survive led them across the sub-Saharan desert in the company of thousands of other displaced youths collectively known as “the lost boys.” They scrounged for food and fended off lions, hyenas and rebel soldiers. Finally they reached a U.N. refugee camp in Kenya, where John, Daniel and Panther were among 3,800 lost boys selected for resettlement in the United States.

A documentary crew filmed their amazement and apprehension as they boarded a plane for the flight across the Atlantic. Over the next four years, the filmmakers chronicled their new lives in the United States and the process of adjustment. The result is an award-winning documentary, “God Grew Tired of Us,” a story both of immigration and of the human response to being culturally uprooted.

I saw the film last night at a film festival being hosted this month by the Willmar Area Comprehensive Immigration Reform coalition. One scene particularly stands out in my mind: Daniel and Panther’s visit to a shopping mall at Christmastime, where they’re speechless at the sight of Santa Claus and a towering Christmas tree.

Talk about a moment of culture shock.

What exactly is culture shock? Anyone who travels is probably familiar with some of the signs: unfamiliarity, stress, disorientation, homesickness. It’s a common reaction to being placed in strange surroundings, and it’s often experienced by immigrants, expatriates, international students and anyone who lives or works abroad. The Amigos Web site at San Diego State University describes it this way:

The term, culture shock, was introduced for the first time in 1958 to describe the anxiety produced when a person moves to a completely new environment. This term expresses the lack of direction, the feeling of not knowing what to do or how to do things in a new environment, and not knowing what is appropriate or inappropriate.  The feeling of culture shock generally sets in after the first few weeks of coming to a new place.

Anthropologist Dr. Kalervo Oberg appears to have been the first person to coin the term “culture shock” and to identify its distinct stages: the honeymoon phase, when newcomers often are eager to absorb their new surroundings, followed by a hostile and unhappy phase which eventually gives way to adjustment and even enjoyment.

Although it’s only been within the last 50 years that culture shock has been officially recognized and given a name, it has surely been a common experience in much of human history. One of the most memorable characters in American immigrant literature can be found in “Giants in the Earth,” a saga of Norwegian homesteaders on the Dakota prairie. (The author, O.E. Rolvaag, was the father of Karl Rolvaag, Minnesota’s 31st governor; the book was first published in 1929.) It’s an unflinching look at the difficulties that come with pulling up stakes and settling in a new home. The intrepid Per Hansa takes to homesteading with gusto but his wife, Beret – lonely, homesick and feeling unmoored from all her familiar values and traditions - cannot adapt. Although I doubt Rolvaag, who was himself an immigrant from Norway, would have used the words “culture shock” to describe Beret’s emotional turmoil, he clearly recognized this is how some people react to a new and unfamiliar environment.

In many ways, it’s hardly surprising that cultural transplantation leads to some level of stress or difficulty with adapting. Unfamiliar customs and language barriers can make even the normal daily routine more challenging. Moving from a tropical to a more temperate climate, or vice versa, also involves physical adjustment. Then there are all the cultural assumptions that we take for granted when we’re at home - for instance, our concepts of privacy and social distance.

For many, the adjustment is not easy, especially if they’re transplanted to a culture significantly different from their own. As the global gap widens between the haves and the have-nots, and as people are increasingly displaced by armed conflicts, I suspect the trauma and the adjustment challenges may rise to a level we haven’t previously seen. Partway through “God Grew Tired of Us,” we learn that one of the lost boys who came to the U.S. with John, Daniel and Panther disappeared for a couple of days, broke down and ended up in a psychiatric hospital.

This doesn’t mean everyone who experiences culture shock has a mental health disorder. Most people, in fact, eventually do adjust, although for some it can take many months. By some estimates, approximately half of Americans living abroad never fully integrate into their new surroundings.

How do you know when you’ve arrived, culturally speaking? An online guide for Americans living and working overseas offers some of the mileposts:

– You begin to feel less isolated.

– You reach the level where you feel you can function effectively in the new environment.

– You don’t feel the same frustration or helplessness anymore.

– You find a middle ground where you can converse comfortably in the language.

– You have made friends and can share common enjoyment in leisure pursuits with your new friends.

– You have accepted the differences between your home society and the new society.

This seems to be true regardless of who you are or where you’ve come from. There were some moments of levity in “God Grew Tired of Us” as the lost boys of the Sudan were introduced to an American escalator and the trappings of a city apartment, none of which they’d ever encountered before. You have to wonder, though, what would happen if the situation were reversed. How many of us would have been able to survive in the desert as these young men did?

By the end of the documentary, John, Daniel and Panther have more or less adjusted and have turned their attention to finding and helping their displaced relatives in Sudan. John plans to return and build a clinic. Panther wants to start a school. None of them are bitter. It’s a pretty amazing lesson in how resilient we can be, even in the face of earth-shaking changes in our lives.

For those who are interested, the Willmar Area Comprehensive Immigration Reform is hosting two more nights of its film festival this month. The next film, “La Misma Luna,” will be shown at 6 p.m. Monday, March 22, in the theater at Vinje Lutheran Church. The final film, to be shown at 6 p.m. March 29, will be chosen by the audience.

Photo: Immigrant children at Ellis Island, New York, 1908. Source: National Archives.

The patient safety edition

If you read this blog on a somewhat regular basis, you’ve more than likely noticed I’m a bit obsessed about patient safety. I come by it honestly. Personal experiences such as a case of mistaken identity, which I blogged about in this post, and a close call with a wrong-site surgery, described here, tend to make you highly aware of the potential for things to go wrong.

So I couldn’t let national Patient Safety Awareness Week go by without posting at least a few links to some patient safety-related reading, starting with this excellent New York Times interview with Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, Md. (If his name sounds familiar, it’s because he has done some ground-breaking research on the effectiveness of checklists to prevent errors.) In the interview, Dr. Pronovost delivers some frank talk about hospital safety, especially about preventing hospital-acquired infections.

One of the points Dr. Pronovost makes is that health care professionals are often their own worst enemies when it comes to providing safer care. Why is this? Most doctors are smart, perfectionistic and dedicated to high standards, but their training doesn’t seem to have prepared them well in the skills required to understand patient safety issues or to work collaboratively in analyzing errors and designing safer systems. This is the premise of a newly issued report, developed by the Lucian Leape Institute at the National Patient Safety Foundation and titled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care.”

Here’s an excerpt that lays it on the line:

Medical schools today focus principally on providing students with the knowledge and skills they need for the technical practice of medicine, but often pay inadequate attention to the shaping of student skills, attitudes, and behaviors that will permit them to function safely and as architects of patient safety improvement in the future. Specifically, medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care, to wit: systems thinking, problem analysis, application of human factors science, communication skills, patient-centered care, teaming concepts and skills, and dealing with feelings of doubt, fear and uncertainty with respect to medical errors.

The full report can be downloaded here.

At the Agency for Healthcare Research and Quality, the Web-based morbidity and mortality rounds feature an ongoing series of “Perspectives on Safety.” In-depth articles and interviews with experts explore issues such as health literacy, disruptive physician behavior, surgical errors, medication bar coding and more. It quickly becomes clear that patient safety is complex, involving multiple factors that cannot be changed overnight.

Then there’s the human side of patient safety. Paul Levy, president and CEO of Beth Israel Deaconess Medical Center in Boston, is known as an advocate for patient safety and transparency. He also happens to be a prominent blogger at “Running a Hospital,” so when it was his turn a year ago to host the medblogosphere’s weekly grand rounds, he chose to collect personal stories about medical error. The result is “When things go awry.” Take some time to follow the links and read all the stories, which represent the experiences of health care professionals as well as patients.

It’s not hard to sympathize with patients and families when something goes wrong. But what about the doctors, nurses, pharmacists and other health care providers involved in an error, especially when it’s an error that harms or kills a patient? I think it’s safe to say clinicians invariably suffer as intensely as the patient and family – maybe even more so - yet often receive little support to help them heal. Caring for clinicians after an adverse event has long been a missing, but vital, piece in the response to medical error. A symposium last year, sponsored by a coalition that included Medically Induced Trauma Support Services of Massachusetts, explored this missing link and what can be done to support health care professionals more effectively. The full report is posted on the MITSS Web site and can be downloaded here.

I’d be remiss if I didn’t also post some basic information for patients and families about what they can do to reduce the likelihood they’ll be on the receiving end of a medical error. Here’s the National Patient Safety Foundation’s patient and family safety page, which contains several links and other resources. The Web site of the Minnesota Alliance for Patient Safety is here. And here’s the consumer medication safety page of the Institute for Safe Medication Practices; it contains a lot of valuable information about the safe use of prescription and over-the-counter medications.

I think we need to be careful about overplaying the ability of patients to influence the safety of their own care. Many things can go wrong over which patients have little, if any, control, and the guilt and self-blame they may feel after an adverse event should not be underestimated. But there are many things patients can do that help make a difference. A little knowledge and empowerment often go a long way.

Update, March 15: Here’s an insider’s perspective from Dr. Pauline Chen, who writes for the New York Times about the doctor-patient relationship. The online discussion can be found here. A couple of thoughts come to mind. First, what Dr. Chen describes seems to be more than a culture of fear; it’s also a culture of hierarchy and dysfunction, in which incident reports about patient harm are used as a weapon instead of a tool for learning. Second, judging from the readers’ comments, it’s incredibly difficult to have a constructive conversation about how to improve patient safety. Doctors get defensive; the public resorts to doctor-bashing. How are we supposed to make any progress in the face of this siege mentality?

A medical home

A month or so after the sad events alluded to in this post, I adopted a new cat from the Hawk Creek Animal Shelter here in Willmar. One of the stipulations of the adoption contract was to bring my new kitty for a veterinary checkup within two weeks – not necessarily because there was something wrong with her but to get her into the veterinary system and make sure a medical file was established for her. As an incentive, the Humane Society of Kandiyohi County even provided a coupon for a free veterinary visit at one of half a dozen participating veterinary clinics in the area.

Everyone, it seems, needs a medical home. Even our animal companions.

The term “medical home” or “health care home” has been around for many years. It was first used back in the late 1960s to refer to a central place where a child’s medical record was archived. More generally, it means the location, usually a primary care clinic, where patients receive most of their ongoing care. Regardless of how you define it, though, we’re going to be hearing it a lot more frequently in upcoming months as Minnesota rolls out its new “health care home” model this year. Last weekend the Minneapolis Star Tribune featured an article describing how the concept is supposed to work:

While the national health care debate has become mired in an acrimonious mix of ideas and insults, Minnesota is moving ahead, putting in place the building blocks of a landmark 2008 state law designed to improve medical care, keep Minnesotans healthier and ultimately trim soaring costs.

The first of the big changes – the “health care home” – will debut July 1 and then spread across the state, with perhaps one-fourth of the state’s 700 clinics certified to offer their sickest patients this new model of care by 2012.

Go to Staples, 150 miles northwest of the Twin Cities, and you can glimpse at the medical future now. That’s where 11 family-practice doctors at Lakewood Health System are using the approach to see whether they can offer better and sometimes cheaper care for 524 patients with the most complex conditions.

Minnesota isn’t the only state doing this. There are currently more than 90 initiatives across the United States to implement a patient-centered health care home model, and at least one version of the federal health care reform bill contained funding for additional pilot projects. (I haven’t been able to find out whether this funding remains in any current form of the bill.)

At first glance, it doesn’t seem all that radical. Health care providers in Willmar have been using various pieces of the concept for quite some time – for instance, a collaborative project at Family Practice Medical Center to improve the management of congestive heart failure. The Willmar Regional Cancer Center is another local service that has adopted a form of the case-management model for caring for its cancer patients.

In the larger picture, however, it’s a very big deal for the promise it holds of transforming the way primary care is provided: more time for patients who need the most attention, more teamwork, better management of chronic conditions, and, ultimately, improved patient outcomes.

How, exactly, does the medical-home concept work? An in-depth article that appeared in the winter edition of Proto, the magazine of Massachusetts General Hospital, describes a medical home pilot project in Vermont, using the example of a man in his 30s newly diagnosed with diabetes:

Pre-medical home, he might have gotten a session with a nurse educator to talk about monitoring insulin levels and giving himself daily shots, and perhaps to go over recommendations for diet and exercise. But it would have been his job to make follow-up appointments to measure his blood sugar, and no one would have had time to check whether he was going to the gym and losing weight.

With the new system, he gets frequent calls and e-mails from staff members alerted by a computerized patient-tracking system. The team’s nutritionist has designed a reduced-carbohydrate diet and an exercise plan for the man, who meets with the team nurse monthly. He has lost 45 pounds and is managing his diabetes without insulin.

At Lakewood Health System in Staples, the physicians decide which patients should be assigned to a health care home. From the Star Tribune article:

Every medical home patient gets a doctor visit of at least 30 minutes, double the usual time. All 11 primary care doctors reserve several slots a day for medical home patients who need immediate care.

“We were getting frustrated. We didn’t seem to have enough time for the patients who needed us most,” said Dr. John Halfen, 60, medical director at the Staples clinic and the driving force behind the new system, now 16 months old. “I’m not working less now, but I feel like I’m accomplishing more.”

Depending on the patient, the health team might include a pharmacist, a psychologist, a specialist, a physical therapist, a home health nurse, the patient’s spouse, even a hospice coordinator or nursing home worker.

But it’s the care coordinator – a registered nurse and the first point of contact – who keeps the system humming.

The real clincher is that, starting July 1, health insurers will begin paying care coordination fees to providers to help support the extra resources they’re investing in medical-home patients. Lack of money has long been the stumbling block to providing more comprehensive care for patients when they need it, and it’s one of the reasons why most clinics simply haven’t been able to coordinate care to a greater extent.

If the medical-home concept works the way it’s supposed to, the money invested up front will be reaped in cost savings with fewer hospitalizations, fewer complications and better overall use of the medical system. Here’s more from the article in Proto (it’s a lengthy article, but if you want to learn more about the medical home model, I’d recommend taking the time to read it from start to finish):

Yet hopes are high that the medical home model could be at least part of the solution to out-of-control health spending, as well as addressing concerns about quality. A 2004 study by the Future of Family Medicine Project, a collaboration among seven national family medicine organizations, estimated that total health care costs would decrease almost 6% if medical homes became the norm, saving some $70 billion annually. And one major proponent of the model – the Patient-Centered Primary Care Collaborative, a coalition formed in 2006 by IBM and other businesses that has grown to include more than 700 members, including large employers, insurers, consumer groups and physicians – suggested in a report that the patient-centered medical home, “if appropriately conceived and properly implemented,” could transform the U.S. health care system.

Obviously we’re not there yet. But early results indicate the model does indeed help hold down costs – and both patients and clinicians are generally happy with how it has transformed the way primary care is provided and received.

If I have a criticism, it’s this: Most of the medical home initiatives, including the one in Minnesota, focus on those who are already sick, have chronic conditions or need a lot of care management. To be sure, this is a patient population that requires attention. By all accounts, the cost of chronic disease in the United States is going to continue rising, so it’s critical to manage these patients as well as possible.

But if one of the goals is to shift the focus of the American health care system from an acute care and disease intervention model to one of wellness and disease prevention, it’s hard to picture how this can happen when the model doesn’t include patients who are farther upstream – in other words, folks who are healthy to begin with and whom we want to keep healthy. Transformation needs to start somewhere, of course, and it makes sense to start with those who have the most complex needs. In the long term, however, I’m not sure how much change we’ll be able to accomplish if we continue to invest our resources primarily on sickness.

The medical home, in its broadest sense, refers to where patients receive most of their care, sick or well. Most studies have concluded that when there’s continuity, when patients have a health care team who knows them well, they generally fare better overall. But many Americans simply don’t have a health care home. Maybe they only see a doctor when they’re sick. Maybe they’ve never really established an ongoing relationship with a physician or clinic and don’t have someone whom they consider to be “their” doctor. If they’re uninsured, they’re probably outside the system altogether. Until we can bring more of these people into the fold, so to speak, I’m not convinced that American health care will truly be able to transform itself the way we envision.

So, back to my cat. I made the appointment at the same veterinary clinic where we’ve been a client for many years. The shelter gave me a copy of my new cat’s health and vaccination record, which I brought to our visit so it could be copied into her new medical file. We put her on the scale, with good news: Her weight is perfect (although the veterinarian informed me that we wouldn’t want it to get any higher). The scanty fur below her right ear suggests she may have had ear mites or an ear infection at some point, but both her ears now look entirely normal. There’s some tartar on her teeth, so she’ll need a dental cleaning some time this year. All in all, she’s a healthy and happy 5-year-old cat. She not only has a home, she also has a medical home and it’s going to be all to her benefit.

If we can do this for pets, surely people deserve no less.

Photo: Wikimedia Commons

The agony of defeat

The Winter Olympic games are over. The athletes have all gone home. Some have medals (way to go!) but most do not. For every athlete who won gold, there was another who finished dead last.

The thrill of victory is wonderful for those who experience it, but what about the agony of defeat? How do you handle the emotional blow of being a loser without, well, being a loser about it?

It’s one of life’s hard lessons, usually encountered early in childhood, that you can’t always be the winner. Most youth athletes perform on a much smaller stage than the Olympics, but that doesn’t make defeat any easier to swallow, explains Dr. Claudia Reardon of the School of Medicine and Public Health at the University of Wisconsin. Here’s her perspective for parents and other adults who work with young athletes (it’s advice that could equally apply to kids in other competitive activities such as spelling bees and math contests):

"Youth sports can be a really physically and emotionally healthy activity, but the reality is that not every bounce, play or game is going to go your child’s way," says Dr. Reardon. "The way you choose to handle can really help them grow, both as individuals and as athletes."

Step one is to acknowledge your child’s feelings. While they’re likely to take things to a catastrophic extreme when they come up short or their last-second shot bounces off the rim (think phrases like "I’m the worst player EVER" and "My life is ruined!"), you can help them take a more measured approach.

"Saying something as simple as, ‘I understand you’re feeling upset that you didn’t win the race’ can open up a discussion and let them know you’re there to listen," says Dr. Reardon. "And it’s OK if the conversation stops there; some children need to work through the disappointment on their own."

Plenty of adults seem to struggle with this themselves. Bad sportsmanship is getting a lot of attention these days. You have to wonder what it says about someone’s emotional disposition when his response to winning a silver medal in men’s Winter Olympics figure skating is to snark about the gold-medal winner’s failure to include a quadruple jump in his routine. Or what it says about the adults who think it’s acceptable to swear at coaches and referees and, in some extreme cases, get physically assaultive. Self-control, anyone?

I’m not sure it helps when certain athletes are uber-hyped by the media. It puts them under heavy pressure to succeed, with the implication that anything less than a gold medal constitutes failure. Not only do their fans expect them to win but there might be, as in the case of South Korean figure skater Kim Yu Na, millions of dollars’ worth of endorsements at stake. And what about their teammates, who are often equally hard-working but don’t get the same amount of attention?

In spite of the pressure-cooker of the world’s most elite sports event, though, there were many moments of Olympic grace, among the winners as well as the losers. These athletes displayed what I like to think of as emotional resilience, the ability to hold up under stress and not resort to negative, potentially destructive thought patterns and behaviors. It’s what makes a skater go out on the ice, land a great performance and win a bronze medal less than a week after unexpectedly losing her mother. It’s what makes a skier come back and compete the day after painfully wiping out in the slalom.

There’s been considerable study in recent years of emotional resilience. It has been linked to better health outcomes, increased resistance to stress and an increased capacity to recover from stress. Researchers are looking at how resilience can be fostered, especially in high-stress situations such as combat, trauma, loss or catastrophic illness.

Why are some people more resilient than others? Is it because of nature or because of nurture? We haven’t quite unlocked all the secrets of resilience but most of us know this quality when we see it.

In the end, these are the best lessons I’d like to take home from the Winter Olympics – not who won or lost but how well and how resiliently they played the game.

Photo: Associated Press