Moral Choices for Today’s Physician

Donald M. Berwick
JAMA. 2017;318(21):2081-2082.

Here is an excerpt:

Hospitals today play the games afforded by an opaque and fragmented payment system and by the concentration of market share to near-monopoly levels that allow them to elevate costs and prices nearly at will, confiscating resources from other badly needed enterprises, both inside health (like prevention) and outside (like schools, housing, and jobs).

And this unfairness—this self-interest—this defense of local stakes at the expense of fragile communities and disadvantaged populations goes far, far beyond health care itself. So does the physician’s ethical duty. Two examples help make the point.

In my view, the biggest travesty in current US social policy is not the failure to fund health care properly or the pricing games of health care companies. It is the nation’s criminal justice system, incarcerating and then stealing the spirit and hope of by far a larger proportion of our population than in any other developed nation on earth.  If taking the life-years and self-respect of millions of youth (with black individuals being imprisoned at more than five times the rate of whites), leaving them without choice, freedom, or the hope of growth is not a health problem, then what is?

The article is here.

Moral Distress in Physicians and Nurses: Impact on Professional Quality of Life and Turnover.

C. L. Austin, R. Saylor, and P. J. Finley
Psychological Trauma: Theory, Research, Practice, and Policy, 2016

Abstract

Objective: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital.

Method: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale–Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one’s professional quality of life. Relationships between these constructs and clinicians’ years in health care, critical care patient load, and professional discipline were explored.

Results: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%.

Conclusion: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

The article is here.

When Bad Doctors Happen to Good Patients

By Thomas Moore and Steve Cohen
The New York Times
Originally published August 31, 2015

Here is an excerpt:

That Lavern’s Law wasn’t allowed to come up for a final vote is Albany’s shame. The greater shame is that hospitals don’t put more emphasis on patient safety. As the Lavern’s Law travesty makes clear, we need better solutions. Don’t limit what injured people may collect, and don’t make it more difficult for victims to get their cases heard. Even better for all concerned, keep the negligent act from ever happening in the first place. And there are practical ways to do that.

Doctors and hospitals must do a better job of policing themselves. Six percent of all doctors were estimated to be responsible for 58 percent of all malpractice payments between 1991 and 2005. State licensing agencies must do a much better job of keeping those worst of the worst out of hospitals. The threshold for state medical licensing agencies to initiate reviews should be reduced; in New York it takes six malpractice judgments or settlements. It should be three at most.

The entire article is here.

Rethinking Hospital Restraints

Thousands of patients are physically restrained every day for their own safety—but evidence suggests that the practice may be ineffective and even harmful.

By Ravi Parikh
The Atlantic
Originally published August 18, 2014

Here is an excerpt:

Most of us who have been hospitalized have never seen physical restraints, as they are rarely used outside the ICU. Examples include wrist and ankle belts, vests, mitts, and full-length side rails attached to the bed. According to Medicare guidelines, restraints should only be used to ensure the safety of patients and staff and should be removed as early as possible. There are only a handful of situations where Medicare and other physician groups recommend using restraints, including patient violence towards himself or others and a threat of a patient disrupting his or her life-saving therapy, such as a breathing tube.

The entire article is here.

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it.

By Sheryl Cash
amdnews.com
Originally posted August 26, 2013

The University of Pennsylvania Health System and its affiliates recently joined Cleveland Clinic and other hospitals in banning the employment of smokers. Proponents say such policies lower health care costs and improve employee and community health. Others believe these restrictions may be the beginning of a slippery ethical slope in which employees can be fired or banned for personal decisions and activities unrelated to their specific jobs.

The question is: Will and can private physician practices soon follow suit, banning or disciplining employees not only for smoking but also for other outside activities deemed detrimental to the image of the group? What about obesity, social media presence, hobbies and other after-work activities? Are there legitimate situations where the needs and mission of the practice, and the protection of its patients, outweigh the individual rights of the employee and potential employee? In general, are these types of bans legal and ethical?

The entire story is here.

When Harm in the Hospital Follows You Home

By Olga Pierce
ProPublica
Originally published March 21, 2013

A slip of the scalpel, an invisible microbe, a minute miscalculation. It's estimated that something goes wrong for more than one million people per year during a visit to the hospital. Some patients experience a full physical recovery. Some are never fully healed.

But even if patients are lucky enough to physically heal, their lives may never be the same. Sleep becomes elusive, relationships break apart, and a wall of silence appears between patients and the doctors they trusted.

What follows is a conversation of sorts between some of the 1,550 members of our ProPublica Patient Harm Facebook community and Dr. Gerald Monk, a professor at San Diego State University who specializes in dealing with the aftermath of patient harm for both patients and providers. We asked group members to share their questions and thoughts about the aftermath of patient harm, and then got Monk’s response. What emerges is a portrait of the long journey that begins after the unthinkable happens.

The entire interview is here.

U.S. proposes scrapping some obsolete Medicare regulations

By Reuters
Originally published February 13, 2013

The Obama administration on Monday proposed eliminating certain obsolete Medicare regulations, a move it said would save hospitals and other healthcare providers an estimated $676 million a year, or $3.4 billion over five years.

The Department of Health and Human Services described the targeted regulations as unnecessary or excessively burdensome and said their proposed elimination would allow greater efficiency without jeopardizing safety for the Medicare program's elderly and disabled beneficiaries.

"We are committed to cutting the red tape for healthcare facilities, including rural providers," Health and Human Services Secretary Kathleen Sebelius said in a statement.

"By eliminating outdated or overly burdensome requirements, hospitals and health care professionals can focus on treating patients," she added.

Industry representatives largely welcomed the changes, saying the proposed rule would help hospitals free up more resources for patient care.

"There are a number of particularly meaningful provisions in the proposed rule," said Chip Kahn of the Federation of American Hospitals.

The American Hospital Association, though, said it was disappointed the administration did not allow "hospitals in multi-hospital systems" to have single integrated medical staff structures.

"Hospitals are delivering more coordinated, patient-centered care and (the administration) should not let antiquated organizational structures stand in the way," AHA President Rich Umbdenstock said in a statement.

The entire article is here.

The Ratings Game

Online physician-review sites pose legal challenges

By Andis Robeznieks
ModernHealthCare.com
Originally Posted: November 10, 2012

People who sue people may receive more undesired attention than anyone else in the world.

That is the general idea behind the “Streisand Effect,” a phenomenon that occurs when an attempt to stifle publicity creates more publicity for something that might never have received much attention in the first place.

According to legend, the term was coined when singer Barbra Streisand tried to have a photo of her home—one among thousands of pictures that were part of an online display showing coastline erosion in California—deleted from that site. The ensuing publicity essentially guaranteed the image will never disappear from the Internet.

It could be unlikely that combative efforts to counter negative profiles on physician review websites will lead to a similar occurrence known as a the “Dr. McKee Effect,” but no one can predict how these things turn out.

Dr. David McKee, a neurologist from Duluth, Minn., is suing a patient's family member for defamation after the man posted negative reviews of him online. The case was argued in September before the Minnesota Supreme Court and, while its legal precedent-setting impact might not extend beyond the state's boundaries, attorneys for both sides say it could serve as a guide in future legal proceedings—wherever the jurisdiction may be.

The entire article is here.

China passes mental health law to curb unnecessary hospitalizations

CBS News
Originally posted October 26, 2012


China's legislature on Friday passed a long-awaited mental health law that aims to prevent people from being involuntarily held and unnecessarily treated in psychiatric facilities - abuses that have been used against government critics and triggered public outrage.

The law standardizes mental health care services, requiring general hospitals to set up special outpatient clinics or provide counseling, and calls for the training of more doctors.

Debated for years, the law attempts to address an imbalance in Chinese society -- a lack of mental health care services for a population that has grown more prosperous but also more aware of modern-day stresses and the need for treatment. Psychiatrists who helped draft and improve the legislation welcomed its passage.

The entire story is here.

Conflicts Arise As Health Insurers Diversify

By Jay Hancock
Kaiser Health News
Originally published April 29, 2012

Like hospitals and doctorseverywhere, Banner Health fights a daily battle to get paid by insurance companies and government agencies for the care it delivers.

So the hospital system hired a company called Executive Health Resources to fight back against the likes of Medicare and UnitedHealthcare when they deny claims or pay bills for less than what Banner thinks it is owed.

But Banner executives began to worry about EHR's independence when the firm was acquired in 2010 by UnitedHealth Group, UnitedHealthcare's parent.

"It does seem as though there is reason for concern because they can use our own information against us," said Dennis Dahlen, CFO of the Phoenix-based Banner.

Critics call United's ownership of EHR a troubling conflict of interest that could give it confidential information about rivals as well as patients and limit EHR's power to demand payment from its much larger corporate sister. "How is that ownership going to affect the mission of a company whose business is to extract more money from payers?" said Scot Silverstein, a physician and specialist in medical software and patient records at Drexel University. "Imagine going to a plaintiff's lawyer to take your malpractice case and not knowing that plaintiff's lawyer actually works for the hospital that you're suing."

The entire story is here.

Report Finds Most Errors at Hospitals Go Unreported

By ROBERT PEAR

New York Times - Health

Published: January 6, 2012

Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.

Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the “adverse events,” according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.

In the report, being issued on Friday, Mr. Levinson notes that as a condition of being paid under Medicare, hospitals are to “track medical errors and adverse patient events, analyze their causes” and improve care.

Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care.

“Despite the existence of incident reporting systems,” Mr. Levinson said, “hospital staff did not report most events that harmed Medicare beneficiaries.” Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.

Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.

The rest of the story is here.

Psychiatric Bed Study in England

Link Established Between More Patients Being Detained In Hospitals Involuntarily And Fewer Mental Illness Beds

Medical News Today

According to a recent study published on bmj.com, in the last 21 years hospitals across England have seen a tremendous increase in the number of patients being detained for mental illness while concurrently there has been a reduction in the number of beds for patients with this disorder. The study was conducted by experienced researchers from the Warwick University, University of London & Queen Mary, and the Newcastle University.

The research has revealed that the reduction in the number of beds for mental illness, which was actually done as part of a policy to maximize the community alternatives for hospital stay, had a direct correlation with the increasing number of involuntary patient admittance to psychiatric centres.

In recent years, with an objective to deinstitutionalise the care of the mentally ill in developed nations, the number of beds for mental illness have been cut back. To achieve this objective, several changes have also been made to the legislation in the UK such as the introduction of the Mental Health Act 1983. Despite efforts such as crisis resolution home treatment, assertive outreach and availability of community mental health teams, a number of countries have seen an increase in the involuntary patient admittance to psychiatric centres.

The increasing use of compulsory detention is quite displeasing among both, the patients and the healthcare providers. Huge expenses involved with in-patient care also make it a source of concern to service providers and commissioners.

The analysis was performed by scientists based on the data available publically in the NHS Information Centre and the Department of Health. The researchers took a note of the hospital activity statistics on the NHS mental illness bed provision and involuntary patient admittance rates, between 1988 and 2008.

It was found that for these two decades, the involuntary patient admittance rates increased from 40.2 % to 65.6 % per 100,000 adults/ year, while at the same time there was a decrease of 62 % in the number of beds for mental illness per 100,000 adults.

When a time delay of one year was applied, a substantial association between these variables was found, with bed reductions preceding the number of involuntary patient admittance. Ultimately, in the following year, the results showed that there was one extra involuntary patient admission for every two beds closed.

The information about the clinical reasons for admissions were not mentioned in the dataset that was analysed; however the authors of the study have stated that it is unlikely that the increase reflects "an otherwise unreported dramatic increase in the prevalence of severe mental disorders in England."  

The researchers conclude,

We emphasise that this paper does not suggest that bed closures are intrinsically inappropriate. This strategy may well be a reasonable course of action; but the bed mix needs to be examined more closely and the rate and consequences of bed closures may need to be considered more carefully. Overall, this study provides important evidence for the need to anticipate the effects of bed closures.

More students are hospitalized for mental health problems

July 2011, Vol 42, No. 7

Print version: page 12

An increased awareness of mental health issues is leading to more college students being hospitalized for psychological reasons, according to new data from the Association for University and College Counseling Center Directors (AUCCCD).

More than 3,700 students were hospitalized for suicide threats and other mental health issues in 2010, a significant jump from the 2,069 hospitalizations reported in 2006, the first year the survey was conducted. The survey found a rate of 7.93 hospitalizations per 10,000 students last year, up from 5.39 hospitalizations per 10,000 students in 2008, a 47 percent increase.

Anxiety was the most commonly cited complaint bringing students in to counseling centers last year, edging out depression as the top reason for seeing a counselor.

One factor driving the increase is that more universities are establishing “students of concern committees,” which coordinate the treatment of students with mental health and behavioral issues who have come to the attention of professors, campus police and residence hall advisers, says Victor M. Barr, PhD, director of the University of Tennessee at Knoxville counseling center.

Compared with years past, most institutions now have specific written policies to help students get treatment and to monitor their progress, Barr says.

The survey also found that:

• 75 percent of directors reported needing additional psychiatric services for students.
• 25 percent of students seen in counseling centers were already taking psychotropic medications.

As a result of increased demand for services, campus counseling centers are getting budget approval from their institutions to hire more psychiatrists and bring on more case managers to track treatment referrals, says Dan Jones, PhD, AUCCCD president and counseling center director at Appalachian State University.

“It used to be that counseling centers would give clients a list of three therapists and leave it in the client’s hands to get treatment when referred out,” Jones says.