Category Archives: patient safety

‘Questions are the answer’

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The consensus is virtually unanimous: If they want better care, patients need to speak up. But for many, this is easier said than done.

If three decades’ worth of research on patient engagement is any indication, most people tend to suddenly become silent in the doctor’s office. Some studies put the average number of questions asked during the appointment at only two.

How to change this?

Encouraging people to ask more questions and giving them some tools to get started with question-asking behavior is the focus of a newly launched campaign by the U.S. Agency for Healthcare Research and Quality, It’s called “Questions Are the Answer,” and it’s based on a solid body of evidence that when it comes to safe, effective health care, communication matters – not only communication by the doctor but by the patient as well.

The AHRQ campaign is the latest in a widening national effort to better equip patients to become active partners in their care.

What can happen when patients are too passive about asking questions? They could have the experience of Alastair McGregor, whose story appears on the AHRQ website in a collection of videos featuring patients and clinicians. McGregor’s heart rate was excellent but he had high blood pressure, so his doctor prescribed medication to lower it. Unfortunately the medication led to an increasingly irregular heart rhythm – which McGregor didn’t report to the doctor until he wound up in an emergency room.

Lesson learned: If there’s a problem, bring it up, McGregor tells viewers. “This is not a question of just taking my car in to have the oil changed, and sitting there while it’s being done,” he says. “This is me. I happen to be the car.”

The AHRQ campaign makes another key point: These days, good clinicians want their patients to ask questions. The health care team can’t address the patient’s concerns or provide appropriate care if the patient doesn’t speak up, the website points out.

Because it’s all too common for patients to be unsure of what to ask, the AHRQ website offers a list of 10 “starter” questions: What is this test for? When will I get the results? How do you spell the name of that drug? What are the potential side effects?

There’s a cool Question Builder tool that helps patients prepare for a doctor’s appointment by identifying and prioritizing the questions they want to ask. There also are tips for questions to ask during the appointment itself and for following up afterwards.

It would perhaps be unrealistic to think the “Questions Are the Answer” campaign will be, well, the total answer to getting more patients involved in their care. There are plenty of other reasons why patients are reluctant to speak up – feeling rushed through their appointment, not wanting to “bother” the doctor, fearful of looking stupid or having their question ignored or trivialized. Sometimes patients don’t ask because they’re afraid the answer will be something they aren’t yet ready to hear. Sometimes it comes down to health care culture and the openness (or not) of individual clinicians to listening to what their patients have to say. Language and literacy barriers are additional obstacles that aren’t easily overcome.

Instilling confidence in people that their questions are expected – welcomed, even – seems like a major first step, however.

If more proof is needed of the importance of asking questions, consider this: Studies clearly demonstrate that when there’s good communication between doctor and patient, health outcomes are generally better. Exactly how this works isn’t entirely understood, but researchers have measured greater trust, more agreement on the plan for the patient’s care, higher-quality medical decisions, increased adherence and greater shared understanding than when communication is lacking. Moreover, asking questions is considered one of the hallmarks of positive information-seeking behavior by patients.

The only truly dumb question? It’s the one the patient wants answered but fails to ask.

‘The patient is on fire!’

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December 2011: A 29-year-old woman is undergoing minor facial surgery at an outpatient center in Florida when a flash fire erupts. She sustains burns to the face and neck and is airlifted to a burn center.

October 2011: A 68-year-old California woman’s oxygen tube catches fire while a surgeon is cauterizing a wound in her neck. Five months later, she’s still recovering.

September 2009: A woman from Illinois, age 65, dies six days after being severely burned in a flash fire during a biopsy. The hospital subsequently revises its safety policies and puts mandatory training in place for all surgery staff.

Of all the things that can go wrong in patient care, surgical fires are among the most horrifying – so much so that the U.S. Food and Drug Administration recently launched a prevention initiative to educate health care organizations about the causes of surgical fires and provide them with risk reduction strategies. The initiative includes a number of prominent partners: the Anesthesia Patient Safety Foundation, the Institute for Safe Medication Practices, the Joint Commission, the Veterans Affairs National Center for Patient Safety, the American Academy of Orthopaedic Surgeons, the American Society of Anesthesiologists and the American Society of Nurse Anesthetists, among others.

Surgical fires are thought to be rare. Some estimates put the number of surgical fires  at 600 to 650 a year out of millions of surgical procedures performed in the U.S. Other studies have suggested they’re much less common, citing fewer than 100 a year. But because many states don’t require hospitals and surgery centers to report them, the true incidence is unknown, and surgical fires in the U.S. likely are significantly underreported.

What’s more, most patients and families are unaware of the risk. Ann Grice, the mother of the Florida woman whose face was burned last December, told the Crestview (Fla.) News Bulletin in an interview shortly afterwards, “I am in shock. This is not what happens with a routine outpatient surgery.”

After the death of her mother in 2004 following a surgical fire and subsequent severe complications, Cathy Reuter Lake founded SurgicalFire.org, a nonprofit organization dedicated to raising awareness and providing information about this underrecognized risk.

“While many people have never heard of a surgical fire inside a patient, it happens more frequently than you might think,” Lake writes on her website. “Exact statistics are hard to uncover due to under-reporting and efforts to cover up surgical fires for fear of malpractice suits.”

Regardless of how often they occur, fires that break out in operating rooms are frightening, both for staff and for the patient – the more so since the consequences can be so deadly. Surgical fires also can injure the staff in the OR, damage or destroy expensive equipment and put a surgery suite out of commission due to smoke or water damage or worse.

ORs present a uniquely hazardous environment for triggering flash fires. They contain numerous instruments capable of touching off a fire: surgical lasers, electrocautery units, heated probes, fiberoptic light sources, drills, defibrillators and so on. They contain fuels such as surgical drapes, sheets, mattresses, bandages, alcohol skin preps and breathing circuits. Finally, they’re typically rich in oxygen, which makes it easier for a fire to break out and causes the flames to spread faster and burn hotter.

Based on data collected and analyzed by the FDA, the Joint Commission and the ECRI private research group, the majority of surgical fires have several things in common. Electrosurgical equipment and lasers account for the most frequent ignition sources, and an oxygen-enriched atmosphere was a contributing factor in nearly three-fourths of the cases that were studied. Burns to the patient were most likely to involve the airway, head or face.

The most critical conclusion: With proper precautions, surgical fires are almost 100 percent preventable.

One of the outcomes of the FDA initiative has been the development of a series of recommendations to reduce the risk of surgical fire. Surgery teams are advised to be judicious in their use of supplemental oxygen and to avoid allowing oxygen to accumulate around the surgery site. After alcohol-based skin preparations are applied, the patient’s skin should be allowed to dry before being draped and starting the procedure. Surgery teams should exercise caution in how they wield electrocautery devices, lasers and other tools and how they place them when not in use. Finally, the OR should have a plan for what to do if a surgical fire does break out.

None of this might be very reassuring to patients – and indeed, it’s exceedingly difficult to patients to advocate for safety in the OR when they’re under anesthesia. Nevertheless, there are a handful of things patients can do ahead of time, starting with awareness of the risks and the knowledge that these types of fires are almost entirely preventable.

The Empowered Patient Coalition suggests asking questions: Is the OR team at the hospital or surgery center trained in preventing, recognizing and putting out surgical fires? What precautions do they use to protect patients? Are water and carbon dioxide fire extinguishers readily available in the OR? Vague or unsatisfactory answers may mean the patient is better off choosing somewhere else to go for surgery.

Getting emotional about mistakes in care

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When patient safety is compromised, clinicians often react with guilt, frustration, embarrassment and sometimes anger. Even when the incident is minor, or when the patient wasn’t harmed at all, it’s common for people’s emotions to get involved and for them to sometimes have trouble coping, a new study has found.

The research was carried out in Canada and appears in the latest issue of the Journal of the American Board of Family Medicine.

Although there’s increasing recognition that caregivers often become the “second victims” after a patient is harmed, few studies have attempted to systematically examine how they feel and how they respond, especially in the medical office setting. Using a confidential questionnaire attached to incident reporting forms for a regional community practice medical safety program, the Canadian researchers collected data from physicians, nurses, managers and office staff at 19 family medicine practices in Alberta.

Here’s what they found:

- Across the board, frustration was the most common emotional response to a patient safety incident. It was reported by 48.3 percent of the respondents. About one in three also reported feeling embarrassed, 12 percent said they were angry and 10 percent felt guilty.

- Whether the safety incident was minor or serious didn’t seem to matter. Most caregivers and office staff reported some kind of emotional reaction when something went wrong or when there was a close call.

- The emotional impact was greater when the patient was harmed or when there was a possibility the harm was more than temporary.

- About 63 percent of the respondents reported using a coping strategy to deal with their feelings after an incident. Their most frequent response was to talk to someone else about it. But more than one out of three said they did nothing, and only 17 percent said they told the patient.

- Of note, the physicians in this study were more likely than the rest of the clinic staff to have an emotional reaction to an incident, and were also less likely to use a coping strategy in the aftermath.

Although this was a small study, one of its strengths is that it was based on real-life incidents and how people responded to them, rather than asking for their response to a hypothetical situation. It also captured the smaller-scale mistakes and miscues that can happen in daily office practice – losing or misfiling a patient’s lab report, for instance – where most patients receive the majority of ongoing care.

Most of the patient safety incidents involved in this study were in fact relatively minor, which might account for why frustration, rather than guilt or blame, was the dominant emotional reaction. Other studies have found that anxiety, shame, self-doubt and self-blame are often part of the doctor’s response to a medical mistake – but these studies generally focused on how doctors felt about the worst or most memorable mistakes of their career, rather than the daily ups and downs of primary care.

It’s a side of office medicine that most patients don’t see. Many might not even realize it exists. But whether patients are aware of it or not, it has an impact on care, the study’s authors wrote.

When clinic employees, and doctors in particular, don’t have good coping strategies for dealing with mistakes, they’re at greater risk of burnout and depression, the authors wrote. it also can become a missed opportunity for personal and organizational learning.

“All members of the health care team report experiencing emotions related to patient safety incidents in their practice,” the researchers wrote. “Incidents with minor or no harm still invoked emotional responses from the providers. It is important to understand the impact that patient safety incidents have on the medical clinic as a whole.”

Look alike, sound alike… aren’t alike

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The doctor’s handwritten order was for Provera, a progestin hormone that helps regulate the female menstrual cycle. But a pharmacist misread it as Prozac, an antidepressant – and that was the drug given to the patient until the next day, when the mistake was discovered.

When the order was shown afterwards to several pharmacists, nurses and doctors, they all had trouble reading it. One person thought it was for Proscar, which is used to treat benign enlargement of the male prostate.

This case study, which appeared in a recent quarterly publication of the Institute for Safe Medication Practices, could serve as a good example of the confusion – and possible harm – that can result from handwritten drug orders. But it’s also an example of something else: the proliferation of look-alike, sound-alike drug names and the potential this carries for making mistakes.

A recent commentary in the International Journal of Clinical Pharmacy tackles this long-standing issue by talking to quality and safety experts who outline the extent of the problem and identify a number of best practices that help reduce the risk of confusion. Eliminating handwriting in favor of computerized order entry is one solution, obviously, but the problem goes deeper than this.

There are many, many drug names, both brand and generic, that are similar to each other. The ISMP has compiled an eight-page list of look-alike, sound-alike pairs involved in errors reported to its National Medication Errors Reporting Program, and it’s a little frightening to see how many opportunities there are for mix-ups to occur.

Actonel vs. Actos, for instance. Adderall and Inderal. Fioricet and Fiorinal. Oracea and Orencia. Precose and Precare. Xanax and Zantac. Some are a triple-header: Celebrex, Celexa and Cerebyx.

All told, about 1,500 drugs have names that look or sound similar. By all accounts, errors associated with look-alike, sound-alike drugs that actually reach the patient aren’t common; mix-ups are thought to happen with fewer than 1 percent of the 3.9 billion prescriptions dispensed annually at U.S. outpatient pharmacies. This still equates to thousands of individuals, however, and sometimes the results are lethal.

As the journal commentary explains, issues such as distractions, interruptions, worker shortages and the fast pace behind the pharmacy counter all contribute to the risk of mistakenly dispensing the wrong drug. But it surely doesn’t help when so many drug names look alike and sound alike. To compound the problem, many drugs also come in look-alike packaging.

One solution would be for manufacturers to choose drug names that are less likely to be confused. After reports that Kapidex, a drug approved in 2009 to treat heartburn, was being confused with Casodex, which is used to treat prostate cancer, the company renamed the drug at the request of the U.S. Food and Drug Administration. Unfortunately there are still hundreds of older drugs on the market with look-alike, sound-alike names that are unlikely to be changed without creating a whole new source of confusion. Nor is the problem limited to brand names – for example, sulfadiazine, an antibiotic, has an extremely similar generic name to sulfasalazine, a drug used to treat ulcerative colitis.

Other strategies include the use of “tall man” lettering to draw more attention to the dissimilarities in drug names that otherwise look and sound alike. Studies have found this helps reduce the possibility of errors. But it’s only a partial fix to a complex problem.

Where do patients fit into this? Most mix-ups involving look-alike, sound-alike drugs happen at the prescribing or dispensing level, so the role of patients in catching mistakes is often overlooked. But there are a handful of things the consumer can do that would help.

Know both the brand name and generic name of the medications you’re prescribed, and how they’re spelled. If necessary, ask someone to write it down for you. If it’s a medication you take often, know what the pills are supposed to look like. Every time you get a prescription filled, check the label on the bottle to make sure the name is correct, and look inside to make sure the pills are the right color and shape. (At my pharmacy, the label includes a description of what the pills are supposed to look like, e.g. round pink tablet with “20″ inscribed on one side.)

Finally, know what you’re taking the medication for. If you know the purpose for your Zantac prescription is to treat heartburn or reflux disease, you’ll be more likely to notice if your prescription has been inadvertently filled with Xanax, an anti-anxiety medication.

Afraid to err

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There was dispiriting news this week from the patient safety front: Despite efforts by hospitals to create a culture that encourages employees to report their mistakes, many still fear they’ll be punished for doing so.

The U.S. Agency for Healthcare Research and Quality issued a report this month on the state of safety culture in U.S. hospitals. It’s the second such report in five years, and the results show minimal progress in developing non-punitive responses to medical errors.

Survey information was collected from nearly 600,000 workers at 1,110 hospitals across the U.S. Half said they felt their mistakes were held against them, and 54 percent said that when an adverse event was reported, it felt “like the person is being written up, not the problem.”

Two-thirds worried that their mistakes were kept in their personnel file. Less than half were comfortable speaking up and questioning the actions of someone in authority.

Some of the survey findings were downright scary. Nearly 40 percent of the survey respondents said it was only by chance that more mistakes didn’t happen at their hospital. About the same number believed hospital management is only interested in patient safety when there’s an adverse event.

Is this perception or is it reality? It’s a little hard to pin down why so many hospital workers responded to the survey the way they did. Even if their attitudes are based on belief rather than fact, however, the outcome is the same: People don’t speak up if their perception, rightly or wrongly, is that they’ll be punished for it.

It’s not enough for hospitals to say they won’t take the shame-and-blame approach to mistakes – they need to show that they mean it, Brian Sexton told American Medical News in an article published this week.

“They say all politics is local. Well, all culture is local. That’s why it is that we say this is so important and yet we don’t see a lot of traction,” said Sexton, a medical psychologist and director of the Duke University Health System Patient Safety Center in Durham, N.C.

“We’ve given more rhetoric than we have resources to this problem in health care.”

Health care isn’t unique in taking a hard approach to human mistakes, but many observers say blame and punishment seem to be especially entrenched in the culture of hospitals and, to a lesser extent, medical clinics. This isn’t necessarily surprising; after all, the stakes are enormous. Patients can be killed or permanently disabled when things go wrong.

Moreover, many who work in health care expect a lot of themselves and those around them. Maybe the health professions are somewhat self-selecting for people who tend to seek control and perfection; maybe some of these attitudes are born out of rigorous training environments. Whatever the case, they can result in merciless condemnation when the inevitable mistake gets made. Fear of being sued and/or ripped apart by the media adds to the pressure even more.

Consider the anonymous nurse in an online nursing forum who was summoned to a case review after a patient was found unresponsive during her shift. She was quickly exonerated of any misjudgment but the process was agonizing, she wrote. “…This feeling of being a horrible cruel person is not what I ever thought would have happened… to me.”

It’s no wonder people are afraid to report their errors.

But here’s an important question: How much of patient safety is about safe systems and how much of it is about safe practices by individuals? In promoting a blame-free culture in hospitals, is there a risk of going too far in the opposite direction and doing away with accountability for reckless or careless behavior?

A nurse responded to Fierce Healthcare’s coverage of the AHRQ survey with this comment:

What is not mentioned in the study is for how many of the respondents, was this the fifth, sixth or seventh error? Where is the line drawn between reporting errors and a negligent practitioner?

A good review process that everyone participates in, is the way to distinguish between the inadvertent error, perhaps based upon bad process or other mitigating circumstances and the negligent practitioner. That’s the environment that needs to be fostered.

Some balance seems to be demanded – hospital cultures that are neither heavy-handed nor permissive, that encourage openness about their failures yet take responsibility when things go wrong.

Making this happen isn’t easy but it needs to be done, Sara Singer, an assistant professor at the Harvard School of Public Health, told American Medical News. “I don’t think you should give hospitals a free pass on this. Yes, it’s hard – and it’s critically important that they do it anyway.”

Patient satisfaction: Deadly to your health?

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Do patients truly benefit when health care providers pay attention to the patient experience?

A rather startling new study suggests otherwise. In fact, researchers found that the patients who were the most satisfied with their care also had higher prescription drug expenditures, were more likely to be hospitalized and more likely to die.

How can this be?

Predictably, many in health care are saying “I told you so.” The increasing emphasis on patient satisfaction as a measure of quality care has never sat well with some clinicians – for instance, the anonymous doctor who offered this online reaction to the study’s findings: “Now that the ‘patient satisfaction’ industry has taken root, we will continue to waste billions and billions of dollars on this each year, money that could have gone towards providing genuine health care.”

It’s a valid question to ask. Intuitively, you’d think that when patients are happier with the care they receive, they’re more likely to have a good relationship with providers, more likely to be engaged in their care, ask questions, follow directions and have better outcomes. But whether this is actually the case hasn’t really been tested rigorously enough to prove it; it’s gut instinct, not science.

Let’s back up for a minute and see what the study says. It was published this week in the Archives of Internal Medicine and involved data on cost, health care utilization and patient satisfaction scores for 51,946 adult U.S. patients.

Among the key findings:

- Patients who reported the highest satisfaction with their care were more likely to be hospitalized than patients who were less satisfied.

- Higher patient satisfaction was associated with higher prescription drug costs and higher overall use of health care services, but lower use of emergency rooms.

- Patients who were the most satisfied had a 26 percent higher mortality risk, even after the study’s authors excluded patients who had three or more chronic conditions and who had self-rated their health as poor.

The authors offer several possible explanations for their findings. Patients often expect – and demand – unnecessary drugs and tests, and they’re more satisfied when doctors cave in and give them what they want, even if this amounts to inappropriate or possibly harmful care, the researchers suggested.

Or maybe patients who received more care also were more reliant on their doctors and hence reported higher satisfaction, although the study’s authors note this doesn’t really explain the apparent connection between higher utilization and more patient satisfaction.

I’m not sure what to make of all this. But with all due respect to folks like uberblogger Dr. Kevin Pho, whose headline this week proclaimed, “How patient satisfaction can kill,” I don’t think this study offers proof that efforts by the health care industry to be more customer-centered are bad for patient care.

Patient satisfaction and clinical outcomes are not the same thing. Although there may be a link between the two, this is a far cry from establishing cause and effect.

Perhaps the real issue is that patient satisfaction, at least in some people’s eyes, has somehow become conflated with giving patients whatever they want. Would patients themselves define it this way? I’m not sure they would; they’re often more likely to use words such as “caring,” “compassionate,” “respectful,” “understanding” and “listens to me” when they describe what makes them satisfied.

Perhaps clinicians are judging on the basis of a different scale. Patients can be surprisingly tolerant of a less than stellar outcome – in other words, more satisfied – as long as they feel they’ve been treated like a human being. Clinicians, on the other hand, might be more apt to see a negative outcome as a failure, period.

Maybe we’re simply not very good yet at measuring patient satisfaction, or we’re using indicators that aren’t particularly meaningful. (Who’s selected to fill out those patient satisfaction surveys anyway? I have never, ever been asked to fill one out.)

If health care leaders focus on patient satisfaction to the exclusion of all else, then yes, it has the potential to be detrimental and even harmful. And clinicians who order drugs and procedures in the belief this is what’s needed to make patients happy (and keep their own satisfaction scores high) are not doing any favors for patient care.

But let’s not allow this study to persuade us to throw out the baby with the bathwater. The collective gut feeling of patients like me is that, on some level, caring about patient satisfaction truly does matter.

Distracted at the bedside

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The patient was seriously sick and in the hospital. The doctors had doubled the dose he was taking of a blood-thinning medication to reduce his risk of stroke. But after evaluating his case a couple of days later, they decided to temporarily discontinue the medication and obtain an echocardiogram to make sure the drug was still needed.

A doctor-in-training took the order. As she began entering it in her smartphone, she was distracted by a text message about an upcoming party. She texted a response, the medical team moved on to the next patient… and the order to stop the medication was never completed.

Four days later the patient was rushed into emergency open-heart surgery to stem internal bleeding caused by too high a dose of blood thinner.

This real-life case appears in the online Morbidity and Mortality Rounds of the U.S. Agency for Healthcare Research and Quality and offers an alarming example of an issue that’s becoming increasingly prevalent in health care: the distractions and multitasking associated with information technology.

If the news coverage lately is any indication, there’s reason for growing concern.

The AHRQ case report is but one instance. Although the patient fortunately survived, it was at the cost of a potentially risky emergency surgery and lengthier hospital stay.

A recent article in the New York Times cited several other examples. In one case, a neurosurgeon apparently got distracted while using a wireless headset to make personal calls in the OR, and the patient wound up partially paralyzed. Other examples included a nurse checking airfare prices online during spinal surgery, intensive care unit staffers using hospital computers to visit eBay and Amazon, and technicians texting or talking on their cell phones during surgery.

It had to happen, I suppose. Smartphones, texting, tablets, Twitter and the like are such a common part of everyday life that it’s inevitable they would spill over into the health care setting. What’s concerning are the implications for patient care, where the stakes are so high.

From the New York Times article:

“You walk around the hospital, and what you see is not funny,” said Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center in upstate New York, who added that he had seen nurses, doctors and other staff members glued to their phones, computers and iPads.

“You justify carrying devices around the hospital to do medical records,” he said. “But you can surf the Internet or do Facebook, and sometimes, for whatever reason, Facebook is more tempting.”

“My gut feeling is lives are in danger,” said Dr. Papadakos, who recently published an article on “electronic distraction” in Anesthesiology News, a journal. “We’re not educating people about the problem, and it’s getting worse.”

Patient safety is clearly the most critical issue, but technology may also be exacting a toll on the human connection so essential in health care. Josephine Ensign, a nurse practitioner and blogger in Seattle, last week described an encounter outside a hospital elevator with three employees absorbed in their smartphones.

“Their smartphones collided, and they looked up dazedly, sheepishly apologizing as they stepped on to the elevator,” she wrote. “Then all three resumed communing with their smartphones.”

She writes:

When my father was in the hospital last year, I noticed that his nurses spent much more time on the mobile computer stations outside of his room than they did in direct patient care. He had some terrific nurses, and they told me that they hated how much time they had to spend in checking and entering patient data in the computers. The legitimate use of technology in health care is all in the name of patient safety. But at what cost does it come in terms of the human interaction necessary as the core of all healing?

I’m not sure what the answer should be. Outlawing mobile devices and computers is simply not going to happen; after all, there’s a worthwhile place for technology in health care. And when technology is done well, it can enhance care and increase safety, observes Dr. John Halamka, chief information officer at Beth Israel Deaconess Hospital in Boston and chief information officer and dean for technology at Harvard Medical School.

The real issue seems to lie in the day-to-day details, Halamka writes in a commentary accompanying the AHRQ case study. “Mobile devices are becoming an increasingly important part of the clinical workday. Leveraging the benefits while applying technology and policy risk mitigations will result in their optimal use.”

Read more about it here and here.

Photo: Wikimedia Commons

The case for geriatricians

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If ever there was a case to be made for the importance of gerontology as a medical specialty, it can be found at the GeriPal geriatrics and palliative care blog, where several recent entries focused on the special needs and dynamics surrounding health care for older adults.

One entry explored what’s known as “hospital disability syndrome,” or the downward spiral that can occur among older adults for whom a hospital stay might result in higher risk of falls, delirium, poor nutrition and functional decline.

Another entry raised important issues about the growing use of standard, one-size-fits-all indicators to measure quality of care. While rigorous control of blood pressure and blood sugar is beneficial for the majority of adults, it can result in more medication, a higher risk of side effects and a higher risk of harm for older patients, blogger Ken Covinsky wrote. “A key issue is that quality indicators almost always promote more medical intervention and more medical is not always better. This is especially the case for frail older persons, where the risk of treatments often exceeds the benefits.”

Finally, an entry titled “Too Much of a Good Thing” analyzed a recent study in the New England Journal of Medicine about emergency hospitalizations among older adults due to adverse drug events, and drew two conclusions: First, many of the older patients in the study got into trouble because they were receiving too much of a prescription medication – for instance, too much insulin. Second, many of the less obvious adverse drug events among the elderly, such as drug-induced delirium, can be difficult to recognize in the emergency room and indeed might not be identified at all.

Geriatrics is defined as “the branch of medicine concerned with the diagnosis, treatment and prevention of disease in older people and the problems specific to aging.”

It’s not a specialty that carries much allure. Doctors who specialize in geriatrics tend to earn some of the lowest salaries in medicine. Moreover, in America’s youth-obsessed culture, caring for aging patients with multiple health issues often holds little appeal.

It’s not surprising, then, that the U.S. health care system is woefully short of geriatricians, even as the number of older adults has been rising dramatically. According to the Geriatrics Workforce Policy Studies Center of the American
Geriatrics Society, only 86 students who graduated from medical schools in the U.S. in 2009 chose geriatrics as a specialty. That’s fewer than 1 percent of family medicine and internal medicine grads. And it’s not for lack of training slots, because about half of the fellowships available in gerontology were left unfilled.

The Geriatrics Workforce Policy Studies Center estimates there’s currently one geriatrician for every 2,620 Americans over the age of 75. By 2030, this ratio is projected to fall to one geriatrician per 3,798 older adults.

You could argue that we don’t really need specialists in geriatrics. Why can’t the care of aging adults be managed just as well by internists or family medicine physicians? There’s in fact a fair amount of debate on this point, helped along by confusion on the part of many patients and families about what, exactly, a geriatrician does.

To be sure, many internists and family medicine doctors are skilled and knowledgeable in caring for the elderly. And not everyone who’s old necessarily needs to have a geriatrician, particularly if they’re relatively healthy.

But let’s not underestimate what geriatricians bring to the table. In “The Way We Age Now,” a lengthy article that appeared in 2007 in The New Yorker, Dr. Atul Gawande takes readers into the world of aging, what it means in the medical sense to age, and what it takes to help older adults remain healthy and functional.

Gawande makes many important observations about care of the elderly, one of them being this: “Good medical care can influence which direction a person’s old age will take. Most of us in medicine, however, don’t know how to think about decline.”

And this: “People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable, and to avert at least some of the worst effects.”

Although primary care doctors can certainly fulfill this role, it’s perhaps unrealistic to think they’ll be able to keep up with the new research being added almost daily to what we know about aging. Moreover, it takes both expertise and experience to understand the nuances surrounding geriatric health – to recognize, for instance, that when we talk about rigorous cut-off points for blood sugar levels, it can be harmful to older adults whose bodies don’t function the same way as younger adults and who have much more to lose from side effects such as dizziness leading to falls.

If we can’t buy into geriatrics from the standpoint of enhancing the quality of life for older adults, maybe we’ll be swayed by the economics of what it’s likely to cost if we don’t become better at meeting the health needs that come with aging.

Photo: Wikimedia Commons

Complications of surgery

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A patient advocate who blogs at 2centsdujour has come right out and asked the same question that’s been bothering me ever since the death of Andy Rooney last week: Unexpected and fatal complications from surgery? What happened?

The curmudgeonly CBS commentator must be wondering what happened too. Pat Mastors, who lost her own father to “complications of surgery” five years ago, channels Rooney’s unique brand of bemused crankiness to speculate about the whole situation:

“I died last week, just a month after I said goodbye to you all from this very desk. I had a long and happy life – well, as happy as a cranky old guy could ever be. 92. Not bad. But then I read what killed me: ‘serious complications following minor surgery’.

 “Now what the heck is that?

 “Nobody gets run over by a ‘serious complication’. You don’t hear about a guy getting shot in the chest with a ‘serious complication’. Sure, I didn’t expect to live forever (well, maybe only a little bit), but I was sorta going for passing out some Saturday night into my strip steak at that great restaurant on Broadway. Maybe nodding off in my favorite chair, settling into a good dream of reeling in a 40-pound striper. You know, not waking up. This whole ‘death by complication’ thing is just so, I don’t know…vague and annoying. It bothers me.”

Somewhat surprisingly, most news reports have glossed over the apparent sequence of events: 92-year-old patient undergoes what reportedly was a minor surgical procedure, unexpectedly develops serious complications and dies in the hospital.

No other information is available, so it’s impossible to know what actually happened. But it’s a blunt reminder of the risks patients face whenever they undergo surgery – even when the procedure is minor or routine.

There’s no accurate estimate for how many patients die in the U.S. from complications of surgery. The most widely quoted figure of health care-related fatalities comes from the now-famous Institute of Medicine report, “To Err Is Human,” but the number – 45,000 to 98,000 – is purely an estimate and includes all deaths related to medical error, not just those involving surgical complications. The best available statistic is that about one in six patients undergoing surgery will develop potentially life-threatening complications.

Surgery is risky, period. Complications can range from a bad anesthesia reaction to hospital-acquired infection or technical error by the surgeon. Many of these are considered preventable, and hospitals are under growing pressure to develop safer processes and lower the rate of complications and deaths.

Over the past decade, a considerable body of research has been built on how to reduce surgery-related complications. One intriguing study, published in 2009 in the New England Journal of Medicine, found that lowering the incidence of complications might be only half the picture. Hospitals also need to get better at managing complications when they do arise, the researchers concluded after examining outcomes among 84,000 patients at 186 U.S. hospitals. Other studies have demonstrated the benefit of checklists and protocols to prevent complications such as infection or post-surgery blood clots.

It’s not easy to tease apart the types of complications that are preventable from those that aren’t. The rate of fatal surgery-related complications undoubtedly could be lower than it is, however. Whether the patient is 9 or 90, death is not the outcome anyone would wish for, and it’s not an outcome that should be seen as acceptable.

Photo: Wikimedia Commons

A dose of Midwest Nice

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Apparently it doesn’t always pay to be polite.

A group of European researchers has reviewed the literature on the psychology of good manners and concluded that in high-stakes situations, politeness can lead to misunderstandings – or worse yet, to actual harm.

These rather intriguing findings appear in the October issue of Current Directions in Psychological Science, a journal published by the Association for Psychological Science.

According to the authors, there’s a time and place to be polite – when a friend is showing off a new outfit, for example, and you think it’s unattractive but don’t want to hurt her feelings by saying so. In such situations, being polite is a way of reducing the awkwardness and maintaining the friendship, the authors write.

They point out that we often resort to politeness when we have to communicate something that might offend or embarrass the other person or imply they’ve made a bad choice. The more sensitive the issue, the more likely we are to be polite.

Not that there’s anything wrong with this. “Politeness is obviously a very positive behavior in most cases,” one of the authors, Jean-Francois Bonnefon, said in an accompanying news release.

When it becomes a problem is in high-stakes situations that require clarity, the researchers said. They cite existing studies that suggest politeness can lead to confusion about what the speaker really means. Furthermore, it seems to take more cognitive resources to process the message. ”We must think harder when we consider the possibility that people are being polite, and this harder thinking leaves us in a greater state of uncertainty about what is really meant,” the authors explain.

It’s not difficult to see how this ambiguity would spill over into conversations between patients and clinicians. What do you say to a patient who’s made an ill-judged decision to forego necessary treatment? How do you discuss the patient’s obesity or alcohol use or tobacco use in ways that are honest and realistic?

You could argue that when physicians soft-pedal the message by being polite, patients might not fully understand their risks or be motivated to make good decisions. A study that appeared last year in the Journal of Medical Ethics explored what the authors say is a deeper issue about physician politeness: that it “masks their existential neglect”  of the patient as a person.

On the other hand, patients generally prefer to be treated with respect, and they don’t always respond well to a dose of brutal honesty.

It doesn’t necessarily pay for patients to be polite either. I blogged awhile back about whether nice patients finish first. On the surface, it might seem they do – but when you examine the issue closer, it becomes clear that if “niceness” is equated with acquiescing to whatever the doctor recommends, it’s not always in the patient’s best interests to be docile and polite.

What can be done to reduce the chances that politeness will lead to misunderstandings or result in outright harm? The authors of the European study suggest encouraging people to be more assertive in high-stakes situations where it’s especially important to have clarity.

There could also be non-verbal cues, such as tone of voice, that indicate someone is trying to be polite, the researchers wrote. If these cues could be identified and if people could be trained to recognize them, it might make it easier to interpret polite statements with more accuracy and less confusion, they wrote.

Image: “The Cup of Tea,” Mary Cassatt, 1880