The doctor will see you online now

The concept of an online doctor visit has a certain appeal: quick, convenient and efficient, not only for patients but for clinical practice as well.

In theory, at least, these are the advantages. E-visits have been slow to catch on, though, and to date there have been only limited studies examining their effectiveness. That’s why my attention was caught by this study, published in the August issue of the Mayo Clinic Proceedings, that reports on a pilot study on the use of online primary care.

For two years, from November 2007 through October 2009, patients in the family practice department at the Mayo Clinic in Rochester could register for the e-visit service. More than 4,000 patients signed up. During the two years of the pilot project, there were 2,531 online visits, of which 1, 159 were billable. Forty percent of the time, patients were able to have their problem handled without needing to make an office visit. The online service was used most often for questions involving sinusitis, depression and back pain.

These results suggest there’s a viable future in primary care for online consultation, the study’s authors concluded:

The extent of conditions possible for treatment by online care was far-ranging and was managed with a minimum of message exchanges by using structured histories. Processes previously given as a free service or from nurse triage and subject to malpractice (protocols) were now documented and billed. Patients showed that they could upload digital images and refill prescriptions as part of the online visits. The timing of visits by patients was generally during office hours. Further study of e-visits, in this era of improving quality while decreasing costs, has merit.

There are some significant caveats, of course. For one thing, the pilot project wasn’t open to any and all patients. According to the study, participants were “identified in face-to-face encounters,” meaning they were specifically selected to join the project. (The study doesn’t indicate what criteria were used, although access to the Internet and a certain comfort level with online communication would certainly have been among them.) For another, most of the participants and most of the e-visit users were Mayo Clinic employees and/or their families, which has the potential for skewing the results even further.

Nevertheless, the study offers some reassurance that e-visits aren’t necessarily the digital bogeyman that so many seem to fear. If the public discussion is any indication, consumers tend to welcome the opportunity to consult their primary care doctor via e-mail and are often willing to pay a little extra for the convenience. Physicians, on the other hand, have been more reluctant. Many of them worry that if patients start asking for e-consultations, it will 1) increase the doctor’s workload; 2) patients will abuse the privilege; and 3) the doctor won’t get paid for it.

Make no mistake, these are all valid concerns. The Mayo Clinic study found, however, that patients for the most part used the e-mail service appropriately. The vast majority of messages were sent during normal business hours, not on evenings and weekends. About 25 percent of the participants only used the e-visit service once during the entire two years of the pilot project.

Nor did physicians appear to be unduly burdened by having to respond to patients’ e-mails. The study’s authors found that clinicians were able to handle most of the e-visits during office hours – and because a highly structured template was used for patients to state their problem and fill in the details, it turned out to be surprisingly efficient. About 40 percent of the time, the patient’s issue could be taken care of without needing to schedule an office visit. The e-consultations even gave physicians a chance to bring up screening and preventive measures. In one case, the authors noted, an e-visit for a refill of a prescription medicine for headaches prompted the doctor to order an overdue colonoscopy, which resulted in the detection of a localized cancer.

As for billing, most of the private insurers were willing to reimburse the $35 that Mayo’s family medicine department charged for an e-visit during this pilot project. Medicare and Medicaid unfortunately did not. Medicare patients had to pay out of pocket for the service, and the cost was written off for patients on Medicaid. On balance, this may have been an acceptable tradeoff, however – the convenience could well have been worth it for older patients. The writeoff for a Medicaid e-visit also was less than what it would have been for a Medicaid office visit, the study’s authors noted. The fact that the private insurers agreed to cover online consultations also suggests that third-party payers might be more receptive to e-care than they’re often given credit for.

Medicine still seems to be wrestling with the proper role of information technology in health care. Are computers helpful in caring for the patient? Do they help make life easier for clinicians? In a companion essay to the study in Mayo Clinic Proceedings, Dr. Warner Slack muses about the benefits and the pitfalls:

With such widespread use of the computer by the general public, there are of course real dangers with misuse and overuse, such as depersonalization, true dehumanization, and breach of privacy, and we must be vigilant. With the computer in medicine, however, the problem is not so much overuse as underuse – or, at least, too little good use.

The goal, he concludes, is “not to replace the physician; the idea is to fill a void.”

If I had the option of an online visit with the doctor, I’d jump at it without a moment’s hesitation. Would I pay out of pocket for it? Yes, I would. Would I do my best to use the service appropriately, i.e. not as my personal online 24-hour medical consulting service or as a cheap substitute for when an office visit is truly necessary? I’m pretty sure I would.

Many of the objections to e-communication with the doctor frankly seem based more on perception than on reality. It’s therefore encouraging to come across studies like this one that suggest online doctor visits, when they’re structured carefully, can indeed be a successful model for delivering some types of care.

An interview with the blogger

This blog is taking a summer break and will return the week of Aug. 29.

Ever since I started blogging, I’ve been asked questions about it – why I blog, how I choose topics to blog about, and so on. Since many of the same questions keep coming up, I thought I should share some of the answers on the blog itself. So here it is: An Exclusive Interview with the Blogger About Everything You Wanted to Know.

How long have you been blogging?

I posted the first entry on Dec. 1, 2008. So I’ve been blogging for… let me do the math here… 628 days. This post is the 396th.

Why did you decide to start blogging?

The West Central Tribune and Forum Communications were enhancing the website and looking for ways to make the most of our multiple online news platforms. We were posting video; we were posting audio; we were reporting breaking news on our website; we had an active comment section. The one thing missing was a local blog.

I was already a reader of several blogs, mostly of the news and health care variety, so I had a good idea of what blogging was about. I figured, “Well, heck, I could probably do this.” So I got the OK from the higher-ups and signed up. I keep hoping one or two of my colleagues here in the newsroom will join me in the blogging world, but so far I’m the only one who has crawled out onto this particular limb.

Why did you decide to blog about health care?

I had been covering local health care for more years than I care to admit. It was something I was familiar with, and it’s always good advice for writers to stick to what they know best. More than that, I find health care to be a fascinating and constantly evolving subject. Most people relate to it on a very personal level, and they’re often passionate and opinionated about it; I know I certainly am. I even talk about and read about health care in my spare time (when I have any spare time, that is), which I guess makes me a true nerd about it. There’s an endless amount to learn about health care. Most of the time I feel I’ve only scratched the surface, just enough to be reminded of how little I really do know.

What’s the difference between blogging and writing a news story?

Well, they both need to be credible and accurate. They both should be appropriately sourced. If you’re going to share your opinions, they should have some basis in fact. Beyond this, there’s considerably more latitude in blogging to be creative in how you choose and present your subject. You can explore the realm of ideas more fully. You can adopt an approach that’s more personal and less formal.

There are a lot of issues in health care that can’t necessarily be developed into a news story or a column on the opinion page, but they’re still interesting and worthy of discussion. Blogging is a great vehicle for showcasing these issues, especially if you include links so readers can expand their knowledge.

Blogs have tended to get a bad rap. People often see them as little more than collections of bloviation and/or snarkitude and therefore not deserving of any credibility. I think this is unfortunate. It’s true there are plenty of blogs that fit this category, but there also is a lot of smart, thoughtful blogging taking place. Bloggers have contributed significantly to the public discussion and I think it’s important to recognize this.

How do you come up with topics to blog about?

I look for inspiration from a variety of sources. Often it’s something in the news – a new study that’s been released, for instance, or an issue people are talking about. From time to time I post about health care issues and events that are local. I trawl the Internet on a daily basis, reading various news sites and other blogs to get a sense of what’s happening and what are the really hot topics.

Sometimes personal experience becomes fodder for a blog entry, although I’d caution people against reading too much into this; most of the time the personal experience is nothing more than a starting point. I also keep a list of ideas for potential blog topics. Whenever I think of one, I write it down, so that when the proverbial well runs dry, I have something to fall back on. Overall, though, coming up with a blog topic isn’t as hard as you’d think. What’s hard is having five or six good topics and being forced to choose just one or two because that’s all I have time for.

I’m not a policy or science wonk or a health care IT wonk so I generally avoid blogging about issues that are overly wonky. I try instead to concentrate on what I know about and/or can relate to the best.

I try to aim for variety. Not every post has to be lengthy, but they shouldn’t all be short either. If I seem to often focus on the patient experience, it’s because this is a subject I think many people are interested in and one that tends to trigger further thought and discussion, even when readers don’t actually post comments on the blog.

When I first started blogging, I mostly posted summaries and rehashes of what was already in the news. I guess you could say I was trying to find my voice as a blogger. In the summer of 2009 I started edging more into commentary and a less formal approach. The feedback was positive and I noticed the readership began climbing significantly. It’s a formula that seems to work so I’ve stayed with it.

Although I’ve been blogging for several months now, people are still discovering the blog, often when someone else links to or tweets a post. The number of daily page views continues to go up, which is cool to see.

My sense is that when people visit a blog, they’re often looking for some information or insight, or perspective, or an opinion they can’t necessarily find somewhere else and that invites them to think and explore their own point of view in a way that goes beyond the surface. If they can find that here, that’s great.

How do you find all the links you post?

I try to go directly to the source whenever I can – an article in a medical journal, for instance, or a news story or an entry from someone else’s blog. That’s one of the great things about blogging. You can instantly attribute all your sources by linking to them, sort of like an electronic version of footnotes. I also like being able to give more exposure to other writers and bloggers and recognize their good work.

Sometimes I have to do some research and some surfing around to find the sources I need. Google has become my very good friend. My main requirement for posting a link is that it comes from a source that is reputable and credible. I hope people take the time to follow most of the links because I include them for a reason – to augment the blog entry and give readers the opportunity to learn more.

What are your favorite posts that you’ve written?

Oh, dear. That’s a little like asking a mother which of her children is her favorite. Since you ask, though, one of the posts that was the most rewarding to write was “Harmed by medicine.” In fact it turned into a three-part series, “The second victims” and “The hardest words” being the other entries in the series.

The emotional impact of medical injury is something that has been little studied and even less understood. Most people probably don’t know this, but I’ve had personal experience with a medical injury and it was a very unhappy situation. So I felt it was a topic I not only knew about firsthand but also could articulate in a way that would be authentic and might help readers better understand the emotional dynamics surrounding medical injury. The way patients have historically been dealt with when something goes wrong, and the reactions that accompany this, are instantly recognizable to anyone who has lived it. I was surprised awhile back to discover the post is listed in an online encyclopedia of articles about the impact of medical injury. It was meaningful to me that someone noticed it and felt it should be included.

A couple of other posts that readers really seemed to respond to were “Fearing the needle” and “No respect for the thyroid.” Both of those generated a lot of blog traffic. The use of needles in medical procedures is so commonplace that many providers don’t even give it a second thought, yet for some people the prospect of encountering a needle is terrifying. I’m not sure there’s enough awareness of this, and there should be. When you really think about it, there’s a lot about the medical environment that can be deeply scary to patients, yet everyone is expected to just buck up and get over it. I don’t see that as helpful.

On a happier note, the thyroid post was fun to write. For some reason it struck me that it would be fun to make it a first-person conversation and that the thyroid should be this rather mouthy, cantankerous character with a Rodney Dangerfield complex. That’s one of the really enjoyable things about blogging. You have the freedom to come up with an idea and take the ball and run with it. I also liked writing “Real nurses.” It was one of those posts that just unfolded all by itself.

Readers tend to like it when a blogger posts a rant, so occasionally I’ll post something that’s ranty, at least by my standards. But I don’t like ranting all the time. Variety is the spice of life and all that.

Where do you get your photos?

Some of them are West Central Tribune photos taken by one of our photographers. I take some of the photos myself. Some organizations, such as the CDC, have an image library that’s available for the media. It can be very hard to find photos on the Internet that aren’t protected by copyright, so I also turn quite often to Wikimedia Commons. They have a huge international database of photos that fall under creative commons licensing or are in the public domain, hence aren’t subject to copyright issues. Plus Wikimedia Commons has so many photos, I can almost always find what I’m looking for.

Was that your herb garden in the photo essay last month?

Yes, it was.

When are you going to post a picture of your new cat? We want to see what she looks like.

I’ve tried taking pictures of her but she always wants to play with the camera, so unfortunately many of the shots are either out of focus or the entire frame is filled with a closeup of her paws batting at the camera lens. I’ll keep trying, though.

Have you ever had trolls on your blog?

The vast majority of the commenters have been polite, thoughtful and well-spoken. I welcome comments and I don’t mind if people disagree with me. In fact I expect there will be differences of opinion about what I post. That’s OK, as long as it stays civilized.

I did get thoroughly bashed last year by a couple of commenters on a post titled “Bad Santa.” One of them called me “pathetic.” Whatever. Right back atcha, pal. And for what it’s worth, I think both commenters totally missed the point of the blog. But to answer the question: No, I don’t get many trolls.

Do you think you’ll ever quit blogging?

Well, I don’t know. I’ve heard the lifespan of the average blog is three months, so I’ve already outlasted that prediction. It can be a struggle to keep up with a blog. You have to keep feeding the beast, because if you don’t post something new every few days, people will stop visiting your site. Quickie posts with a link or two tossed in don’t always cut it. Readers often want to see something a little more substantial, and I’d like to be able to encourage this. Quite frankly, many things about life these days feel like speed dating. I would rather not add to this trend if I can possibly help it.

My life would probably be more simple without this blog. Putting together a decent post takes time, thought and creative energy – all commodities that are spread perilously thin in the average newsroom. My goal is to post a new blog entry three times a week, and some weeks it’s really a stretch to do that.

At some point the blog will probably outlive its usefulness. When the time comes, I hope I’ll be able to recognize it and swiftly put the blog out of its misery rather than letting it dwindle to an undignified end. But my sense is this won’t happen for quite awhile yet. Right now I’m having too much fun to think about quitting.

When palliation is the goal


Do people live longer with aggressive care, or do they fare just as well when their care is more focused on helping them be comfortable?

As the dying process becomes increasingly prolonged through the sometimes dubious wonders of medical intervention, it’s an important question to ask.

A new study, published online this week in the New England Journal of Medicine, suggests the glimmer of some answers. It tracked two groups of cancer patients – a cohort randomized to receive early palliative care and a control group that didn’t – and found that patients newly diagnosed with lung cancer reported a better quality of life when palliative care was provided early in the course of their treatment. And despite receiving less aggressive end-of-life care, they also lived slightly longer than patients who did not have early palliative care. They were more likely to have their end-of-life wishes documented in their medical chart as well.

The study involved 151 patients at Massachusetts General Hospital and was conducted over the course of three years, from 2006 to 2009. Since it involved a small, specific patient population, it’s hard to know whether the same findings might apply more broadly. Nevertheless, the study offers some interesting insight on the benefits of palliative care – plus the data to actually measure this.

The study’s authors conclude:

Early integration of palliative care for patients with metastatic non-small-cell lung cancer is a clinically meaningful and feasible care model that has effects on survival and quality of life that are similar to the effects of first-line chemotherapy in such patients. As compared with the study participants who received standard care, those who were assigned to early palliative care had improved mood, more frequent documentation of resuscitation preferences, and less aggressive end-of-life care. Although our findings must be replicated in a variety of care settings and cancer populations, the results nonetheless offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.

It makes a pretty strong case for the more widespread use of palliative care, preferably sooner rather than later in the course of a serious disease. And therein lies one of the most important implications of this study: defining the role of palliation in the care of the patient.

Palliative care seems to suffer from an identity crisis. It traditionally has been viewed as something that’s offered to patients when standard treatment is no longer effective. In the public’s mind – and in the mindset of many health care professionals as well – it’s often synonymous with “hospice” rather than being an entity unto itself. This perception frequently gets reinforced by the tendency to lump hospice and palliative care into the same discussion – to wit, the name of the leading organization in the U.S. for promoting high-quality care at the end of the life, the National Hospice and Palliative Care Organization.

How, exactly, should palliative care be defined? The NHPCO describes it this way: “treatment that enhances comfort and improves the quality of an individual’s life during the last phase of life.” The Center to Advance Palliative Care defines the aim of palliative care as “to relieve suffering and improve quality of life for patients with advanced illness and their families.” And the American Academy of Hospice and Palliative Medicine defines the goal as “to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies.” (emphasis added)

Should palliative care continue to be targeted mainly to people in later stages of an illness with a bleak prognosis? Or should we start offering it farther upstream? If it’s offered sooner, when is the appropriate time to introduce it to the patient and family? Should it be an option for everyone with a serious illness, even when the patient is expected to recover? If health care professionals can’t totally agree on the role of palliative medicine or where it belongs on the continuum, how is the public supposed to know?

(I’d also argue that longer survival shouldn’t be the only measure, or maybe even the most important measure, for justifying the effectiveness of palliative care. For many patients, quality of life matters far more.)

In an accompanying editorial on the study, the New England Journal of Medicine suggests it’s time to rethink our concept of palliative care: “The new approach recognizes that life-threatening illness, whether it can be cured or controlled, carries with it significant burdens of suffering for patients and their families and that this suffering can be effectively addressed by modern palliative care teams.”

Dr. Lyle Fettig at the PalliMed blog goes so far as to call the NEJM study a “game changer” that’s likely to have “important and long-lasting” implications for palliative medicine.

Let’s hope it sparks some serious conversation, because it’s long overdue.

Eating their young

I confess to being a little addicted to “HawthoRNe,” the hospital drama/soap opera in its second season this summer on TNT (it airs at 8 p.m. each Tuesday).

Like so many television dramas, it often strains the boundaries of believability. I’m not even sure why I keep watching it. Maybe it’s the fact that it’s one of the few current shows whose main character, Christina Hawthorne, is a nurse. Maybe it’s the feistiness that actress Jada Pinkett Smith brings to her role as a director of nursing at a troubled urban hospital. If I were a patient, I’d definitely want Christina on my side.

This season started out with the shutdown of the fictional Trinity Hospital in Richmond, Va. Christina and the gang have been transferred to the James River Hospital, where they all miraculously have been given jobs and have promptly encountered nonstop drama, romantic entanglements and internal politics.

There’s all kinds of subplots cooking away this season. Viewers need a scorecard to keep track. The one that really made me sit up and take notice, though, occurred in last week’s episode involving Kelly Epson, a naive and perpetually perky rookie nurse, and two of her nursing colleagues with whom she unfortunately keeps clashing. These two nurses have personalities that are about as pleasant as a nuclear waste dump, and they’re out to get Kelly. I found myself thinking, “Yeah, right, like real nurses would ever do that.”

Or would they? As it turns out, you bet your sweet life they would. Nurses even have their own expression for it: “eating their young.” It takes many forms: hostility, bullying, back-stabbing, sabotage, intimidation. New nurses in particular tend to be the targets of this aggression – and it’s very real, as the online comments on a nurse managers’ forum attest. One nurse who entered the profession in her 40s said her “first and only job was a nightmare!”

Another RN confirmed that “this lateral hostility is still alive and festering.”

It seems more prevalent in the critical care areas (maybe because these nurses are many times aggressive by nature). Many critical care nurses feel their knowledge level is above “floor” nurses and they look down on them and consider them inferior.

Why would nurses, who profess to be so caring, behave this way? One nurse observer suggests it’s because nursing is a high-stress profession in which frustration with working conditions tends to be redirected against colleagues. Theresa Brown, an oncology nurse who writes a column for the New York Times health section, describes in vivid terms how this happens (and be sure to read the comment thread for reactions to the piece):

Spending our shifts feeling pulled in an impossible number of directions, day after day after day, can in the end be too much. A lot of nurses find a way to regroup and stay, while some burn out and quit. But a few nurses will, like cornered animals, bare their teeth and fight back.

The problem is that they don’t fight back against the people who put them in the corner. These overwhelmed and angry nurses take their frustration out on the rest of us stuck in the corner with them, or on anyone – like interns – they perceive as being less powerful than they are.

Not all nurses are like this. In fact, I’d venture to guess the majority are not. I’d also venture to guess that many, if not most, workplaces would like to see this nurse-on-nurse hostility stamped out, not only for the sake of nurses but for the sake of safe patient care.

In the case of “HawthoRNe,” it seems, art is imitating life – in fictionalized, exaggerated fashion, perhaps, but with a kernel of truth behind it.

Team spirit

Teamwork seems to be all the rage right now in health care. Indeed, it’s one of the key elements in the concept of the patient-centered medical home – multidisciplinary teams of physicians, nurse practitioners and other professionals each contributing their skills and united in caring for the patient.

Intuitively it makes sense. No one group, or profession, can do it all alone. There’s a lot to be gained from the expertise of pharmacists, nurses, therapists, social workers and so on that is to the benefit of patients.

I’m always a little bemused when the discussion turns to health care teams. Often the implication is that this is something brand-new, bold and different. The reality is that rural health care has been doing the team thing for many years, and they’ve been pretty darn successful at it. Back when the University of Minnesota offered its (now defunct) Rural Health School program for students in the health care professions, I once interviewed a group of participants who were completing their Rural Health School rotation in Willmar. One of the first things they all commented on was the teamwork they saw among local providers and the level of interdisciplinary participation that was fostered and encouraged.

In some ways, rural providers have been forced into effective teamwork as a matter of sheer survival. They don’t have the resources to draw on that their colleagues in an urban center might have. They’ve had to learn to come up with their own solutions and be more reliant on local partners to help them. Failing to recognize or respect the necessity of teamwork is to be hamstrung in the effort to deliver good care.

Rural providers seem to instinctively know this, even if they don’t articulate it in so many words. Functioning as a team isn’t automatic in health care, however, a point that struck home when I encountered this recent study in the August issue of Health Affairs journal. Simply put, health care professionals aren’t trained in ways that invite teamwork, the authors explain:

Team-based primary care offers the potential to dramatically improve the quality and efficiency of care, but its broader adoption is hindered by an education system that trains health professions in silos… Changes in professional cultures, organizational structures, clinical partnerships, admissions, accreditation and funding models will be required to support the expansion of collaborative education effectively.

It’s the direction in which we appear to be headed, at least in primary care. Some of the motivation obviously is to provide better care for patients. But as the health care system, and primary care in particular, comes under increasing strain, there’s also a need to do more with less and make limited resources stretch further. In other words, to respond in the way rural health providers have already learned to do.

And excuse me for wondering whether the rush toward “teamwork” won’t end up magnifying the inherent flaws in the team approach, to the detriment of patients.

Not everything about team care is peaches and cream. Just ask Stephen Wilkins, who blogs about doctor-patient communication at Mind the Gap. He recently tackled the concept of team care in the patient-centered medical home and concludes “there are a whole bunch of things wrong” with this focus. For patients who want their primary relationship to be with the doctor rather than a doctor or physician assistant, team care can be a hindrance, Wilkins wrote. More players involved can result in more opportunities for miscommunication and for things to go wrong, he points out.

And if you were to ask individual patients, many of them might have clear preferences for how they wish to be cared for, he wrote:

I have nothing against nurses, nurse practitioners or physician assistants. I just prefer to discuss my personal health with my physician of many years. Other people may be quite happy working with physician extenders. The point is it should be my choice who I see for care and not the choice of the physician, physician group, insurance company, government or anyone else.

I’d add a couple more potential issues. People in the health care professions can have strong, take-charge personalities that don’t necessarily serve them well when it comes to playing well with others. This can lead to teams that perhaps look unified on the surface but underneath are fractured with egos and dissent. On the other hand, when power is shared more equally it can mean that no one really has overall responsibility for directing the care of the patient.

When it’s done well, teamwork can enhance patient care. It doesn’t even have to be visible; some of the best teamwork takes place behind the scenes. Rural health care providers aren’t invariably better at this than everyone else, nor are urban and suburban providers invariably worse at it. Successes and failures can and do occur in both settings. But rural providers, on average, seem to have absorbed some of the lessons a little better. There’s a difference between being a team in name only and being a team with genuine esprit de corps. And this difference, although it can be elusive, is critical.

West Central Tribune photo by Rand Middleton

Overburdened in the ER

In February of 2009, things started to change in Rice Memorial Hospital’s emergency room: Staff were seeing a very noticeable spike in patient visits, especially on weekends. As the weeks passed and the numbers showed no sign of diminishing, the ER took steps to adapt. A second physician was added on Sundays. The triage process was strengthened.

As it turned out, this wasn’t just a temporary blip in the statistics. High use of the emergency room has continued this year. As of the end of June, ER visits totaled nearly 6,400 – 3 percent higher than last year.

A couple of new reports issued this past week confirm this isn’t an isolated case. A study published in the Journal of the American Medical Association examined trends in ER use and found the national rate was growing far out of proportion to U.S. demographics. In fact, the increase from 1997 to 2007 was almost twice what would be expected when compared to population growth during the decade. Utilization was especially high among Medicaid patients.

The second report, which comes from the U.S. Centers for Disease Control and Prevention, analyzes ER visits in 2007, breaking them down into categories ranging from patient characteristics to insurance coverage and severity of illness.

Both reports shed much-needed light on what’s happening on the front lines of health care. The JAMA study, for instance, makes clear the increasing burden on ERs as the community safety net. According to the study, nearly two-thirds of emergency departments in 2007 were classified as safety net hospitals, which provide a disproportionate amount of care to patients who are on Medicaid or are uninsured. This is almost double the number of safety net hospitals in 1997, the study’s authors noted. At the same time, the number of emergency departments was shrinking, from 4,114 in 1997 to 3,925 in 2007.

The CDC analysis contains some particularly eye-opening facts. Although it’s often assumed that ERs are clogged with patients who don’t really need to be there, the statistics show otherwise. Of the 116.8 million visits to U.S. emergency rooms in 2007, close to half of these patients either needed to be seen immediately or urgently. Only about 8 percent were considered non-urgent. (The CDC report makes another distinction worth noting: “The term ‘nonurgent’ does not imply an unnecessary visit.”)

Also contrary to popular belief, emergency rooms weren’t filling up with uninsured patients who had nowhere else to go. According to the CDC’s statistics, private insurance accounted for the largest share of emergency-room visits, followed by Medicaid and the publicly funded Children’s Health Insurance Program, then by Medicare. The uninsured actually were the smallest group, at 15 percent.

All of these findings confirm previous studies on emergency-room patient demographics. The limitation of both reports is that they involve data from 2007 and earlier. It seems reasonable to assume, however, that the recession, job losses and loss of health insurance have put even more pressure on emergency rooms as the provider of last resort.

Although the public discussion about emergency room utilization has tended to focus on discouraging unnecessary visits, there are many factors that drive emergency room use, and frivolous visits aren’t necessarily at the top of the list. For one thing, ERs are open at night and on weekends, when most physician clinics are closed. In fact, the CDC report found that two-thirds of ER visits during 2007 occurred during non-business hours. For another, the primary-care system is increasingly strained and it’s possible that patients are ending up in the ER because they can’t get an appointment soon enough with a doctor. Hospitals are under pressure to discharge patients sooner, perhaps before the patient is ready, and these people can sometimes end up back in the ER. Rising out-of-pocket costs also might play a role in deterring people from seeing a doctor early in the course of an illness, only to have the symptoms worsen or complications arise that necessitate a trip to the emergency room.

When Rice Hospital officials tried to analyze what was behind the spike in ER volume last winter, they couldn’t pin down any single answer. They did learn, however, that the vast majority of local patients came to the emergency room because they truly needed to be there. On one Sunday in February 2009, for instance, the ER saw 52 patients, half of whom were experiencing chest pain, abdominal pain or difficulty breathing. There were two head injuries and one eye injury. Three patients arrived by ambulance and nine were sick enough to be admitted to the hospital.

Emergency rooms provide a critical community service. But they’re under a great deal of strain, and the strain isn’t just coming from sheer patient volume; some of it originates upstream or downstream as well. It would seem that if we want to gain better control of health care spending and support emergency medicine services more effectively, the solutions will need to address the entire system and not just one piece of it.

West Central Tribune file photo

Power to the patients

The attention being paid to CNN medical correspondent Elizabeth Cohen’s newly published book on patient empowerment suggests a couple of things: 1) There’s considerable appetite among the public for learning how to be better health care advocates for themselves; and 2) Empowerment isn’t something most of us are born with.

Cohen’s book, “The Empowered Patient,” was released this week. In an interview with USA Today, she explained why she wrote it and why it can be so hard for many patients and families to speak up:

Even though I’m an empowered patient, I still have a hard time. I was in the hospital with a family member and he’d just had pretty invasive surgery and they were coming to check his surgical site on a regular basis and I noticed they were not washing their hands.

I don’t like confrontation, so I came up with this way to get what I needed; I made a little joke of it and said, “I’m like (comedian) Howie Mandel. I’m nuts about germs,” and asked them to wash their hands. It’s silly that I needed to come up with a little story, but it worked.

The definition of a “good” patient isn’t what it used to be, and thank goodness for that. At one time, a “good” patient was someone who followed the doctor’s orders, didn’t complain and didn’t rock the boat. This state of affairs might have been better (or less hassle, perhaps) for health care providers but it was decidedly not better for patients. These days there’s almost a universal consensus that patients in fact do fare better when they’re educated and involved in their care, and multiple studies back this up.

Getting this to happen in real life hasn’t been easy, though. Many patients are still socialized to not be too assertive or too quick to speak up, especially if they have concerns about their care. The gap in knowledge between the layperson and the health care professional often makes it difficult for patients and families to know what the right questions should be. They might not even recognize when it might be critical to speak up and ask questions. And at the risk of repeating myself, many people simply aren’t comfortable with an advocacy role.

Health care professionals, for their part, aren’t exactly comfortable either with patients’ new-found activism. A case in point: the debate over giving patients access to their full medical record. Although many physicians and nurses welcome patient involvement, not all health professionals appreciate the discussion and shared decision-making this entails. Patients and families who are outspoken or who ask a lot of questions can sometimes be viewed as troublesome. At times it can lead to defensiveness and a bunker-like mentality that shuts down the give-and-take of patient participation.

It’s a complicated dance, to be sure. When does assertiveness cross the line into being demanding? At what point does appropriate clinical practice trump the patient’s own wishes? What responsibility do health care providers have to encourage more participation from patients? If providers are reluctant to invite patient involvement, doesn’t this send the wrong message?

Elizabeth Cohen’s book may be new but it’s part of a growing body of patient advocacy literature. I didn’t realize how widely this extended until I came across Regina Holliday’s compelling painting, “Give Us Our Dammed Data.” In her blog, she describes the painting as a crowd-sourced portrait of “a citizen army of patient advocate authors”:

It is a very large painting, and yet it is crowded with many who have been hurt and many who have suffered. Every one of them is an author. Most of the authors in the painting took the hurt and outrage they felt about a dysfunctional medical system and channeled that into a book. That book is their shield and a pen is their spear.

For those who haven’t heard of her, Regina Holliday is an artist and advocate from Washington, D.C., whose husband died of cancer last year after a nightmare journey through a frustrating and unresponsive health care system. I’m guessing some of the authors in her mural (Elizabeth Cohen is among them) may have started out as “good” patients whose experiences hammered home the realization that patients can’t just be “good”; they also need to be empowered.

In other words, patient empowerment is at least partially a learned skill. The big question, of course, is how it can be taught so consumers can effectively advocate for themselves. We’re still figuring it out, and some of the lessons with the greatest impact come from patients and families who’ve learned in painful ways the necessity of being empowered.

A new paradigm for pre-meds?

To be admitted to medical school, it has always taken good grades and a strong background in the sciences. Most pre-med students load up on college courses in biology, chemistry, physics and math. Twentieth-century American history or the poetry of Yeats? Not so much.

There’s traditionally been a strong belief that college students pursuing their premedical studies should concentrate on the sciences rather than the humanities, and that this preparation will make them more successful in medical school and ultimately help them become better physicians.

A new study, published in the August edition of the Academic Medicine journal, has come along to punch a few holes into this belief. The title more or less sums it up: “Challenging Traditional Premedical Requirements as Predictors of Success in Medical Schools: The Mount Sinai School of Medicine Humanities and Medicine Program.”

The study involved about 700 medical students at the Mount Sinai School of Medicine in New York. Eighty-five of these students were enrolled in the school’s Humanities and Medicine Program; the rest took traditional coursework. After analyzing and comparing data on academic outcomes for the graduating classes of 2004 through 2009, the authors concluded, “Students without the traditional premedical preparation performed at a level equivalent to their premedical classmates.”

In the interests of full disclosure, I graduated from a liberal arts college where most of my coursework was in the humanities. I’ve been increasingly disturbed at how the sciences are pushed on young people as the ticket to a “good” (read: lucrative) career, the implication being that the humanities don’t hold the same value. So reading about this study in Academic Medicine made my nerdy little English major’s heart skip a few beats.

Among the findings: Students enrolled in Mount Sinai’s Humanities and Medicine Program were just as likely as their peers to graduate from medical school with honors or distinction. Interestingly, they also were more likely to choose residencies in primary care and psychiatry, and less likely to gravitate toward anesthesiology and surgical subspecialties. They did not perform as well on the U.S. Medical Licensing Examination Step 1, which may have been a reflection of their nonscience background or perhaps how the test itself is structured. The study’s authors noted, however, that even with slightly lower test scores, this “seems unlikely to affect their clinical skills or to keep them from securing high-quality residency training positions.”

The Humanities and Medicine Program is intriguing in and of itself. Qualified college sophomores and juniors majoring in the humanities or social sciences who sign up for the program are guaranteed admission to the Mount Sinai School of Medicine. (Lest anyone think it’s easy to get in, it’s not: The selection criteria include high school and college grades, SAT scores, two personal essays, three letters of recommendation and two interviews at Mount Sinai.) Once accepted into the program, HuMed students don’t have to take organic chemistry, physics or calculus, nor do they have to take the MCAT exam. They do have to maintain at least a 3.5 grade point average, however, and they also must earn a B or better in biology and chemistry.

There’s no program like it at any other medical school in the U.S., so it’s hard to know whether the findings from this study can be replicated elsewhere. Nor did the study look at how Mount Sinai’s HuMed graduates fared in clinical practice.

It all raises some interesting questions, though, about how we prepare future physicians here in the United States. Do pre-med students really need to sweat their way through organic chemistry in order to meet the admission criteria for medical school? Do medical schools needlessly skew the application process? Have they tilted too far toward the sciences and away from the humanities, and is this in some way detrimental to producing physicians who are well-rounded human beings?

It’s a somewhat controversial question in academic circles. There’s been little movement, though, to address it more fully, the journal article acknowledges:

Despite general agreement that many premed requirements are of limited educational value for the practicing physician or active scientist and that a broad liberal arts education provides direct benefits to practitioners and their patients, little progress has been made toward a fundamental reappraisal. In 2009, over 80% of matriculating applicants entered medical school with majors other than the humanities or social sciences. The belief that the premed science background (including one year each of organic chemistry, physics, and calculus) is the best form of student preparation for medical school persists, and admissions committees’ reliance on exceptional MCAT scores prevails.

This emphasis on the sciences percolates all the way down to high school and even junior high. Career counselors urge students interested in medicine to start beefing up their science background as soon as possible. It’s thought by many observers that if students wait until their junior or senior year in high school, it’s too late. You can’t help wondering about the long-term impact of this do-or-die channeling of young people’s interests and the academic choices it often forces them to make.

To be a good clinician, unquestionably it takes a strong background in the sciences. Majoring in the sciences does not necessarily turn someone into a soulless robot, just as an emphasis on the humanities doesn’t necessarily guarantee someone will be perceptive and empathetic. It’s worth asking, however, whether a more balanced premedical education would ultimately be better both for doctors and for their patients. This study offers at least some preliminary evidence that it’s possible for medical students to hold their own even when they haven’t spent all their college years in the science lab.

Update, Aug. 11: Here’s a personal perspective on this issue from Dr. Bob Wachter, who majored in political science.

Photo: Wikimedia Commons

Moving day: Aug. 10

The Area Voices blogs, including this one, are scheduled to migrate to the WordPress platform this coming Tuesday, Aug. 10. (It’s possible there might be a last-minute delay, but as of right now this is the date.)

I don’t know how long the process will take or whether the blog will continue to be accessible while the switch is under way. The best advice I can offer is to check here from time to time to find out when the blog will be available at its new site.

I’m told that readers will automatically be redirected to the new site. I’m also told that the blogs will temporarily disappear from the West Central Tribune news site while WordPress is integrated into our content management system. So if you usually access this blog through, you’ll have to go directly to the blog instead. The URL here is The new URL is supposed to be, according to what I’ve heard. If neither of these addresses work and you’re really desperate, you can always try to Google the blog after next Tuesday.

I’ll try my best to keep readers updated on the status.

Photo:Wikimedia Commons