Category: Physicians

Hooray for hospitalists

published date
October 30th, 2006 by

Hooray for hospitalists

Hospitalists, physicians who practice internal medicine solely within the inpatient setting, are profiled in today’s Boston Globe. One of the weirder things about hospitals is there usually aren’t many doctors around. Primary care physicians tend to round in the early hours of the day, and then patients are left with nursing and administrative staff the rest of the time. Hospitalists address that deficiency by actually being in the hospital most of the day.

The article profiles Dr. Faisal Hamada, who runs the hospitalist program at Brockton’s Caritas Good Samaritan Medical Center. He’s actually employed by Cogent Healthcare, an Irvine, CA –not Philadelphia as the article states– based provider of turnkey hospitalist programs. Cogent provides the hospitalists, support staff, protocols and IT systems. The company generates a return on investment for its clients by improving the quality and efficiency of the hospital. Because hospitalists are around they can make adjustments in a patient’s schedule during the course of a day, something a primary care is unlikely to do after rounds . That kind of intervention tends to improve length of stay.

Good hospitalists develop a rapport with community physicians, which is essential so that those physicians don’t feel like the hospitalists are stealing their patients. I’m not surprised that Dr. Hamada is complimentary to the community physicians, but it’s also a fact that hospitalists tend to be more competent working in the hospital than their community-based colleagues. Hospitalized patients tend to be very sick –sicker than office-based physicians are used to seeing. Hospitals also have their policies, procedures, and informal ways of getting things done. It’s easier for a hospitalist to be good at this part of the job than someone who is only in the hospital occasionally.

One of the common complaints about hospitalists, also echoed in this article, is that there is a gap in communication between the hospitalist and the primary care physician, so that patients can get in trouble in between the time they are discharged and the time they see their community doc again. But that actually shouldn’t be such a problem in Brockton. Unlike most hospitalist programs, Cogent has its own call center to follow up with discharged patients, and has specific protocols for communicating with community physicians. In addition, Brockton is one of the three Massachusetts communities that is being wired up with a health information exchange as part of the Massachusetts eHealth Collaborative. That should make it much more straightforward for hospital-based and community-based physicians to stay in touch. Patients will benefit.

Underworked docs in the UK

published date
October 11th, 2006 by

Underworked docs in the UK

An article in the Daily Telegraph, Britain will need to hire thousands more “junior” doctors due to European Union work restrictions. The docs can currently work 58 hours per week, but an EU directive will compel a drop to 56 hours in 2007 and 48 hours in 2009. What’s more, time on call must be counted in the total.

There’s such a thing as a doctor working too many hours, but this is ridiculous.

This conscientious objector case is a little shocking

published date
October 9th, 2006 by

This conscientious objector case is a little shocking

From the Boston Globe (Army-financed doctor granted objector status)

An anesthesiologist whose medical training was financed by the Army must be discharged from the Army Reserve as a conscientious objector, a federal judge ruled yesterday.

Dr. Mary Hanna, for whom the Army paid approximately $184,000 to attend the Tufts University School of Medicine, had been scheduled to report to active duty Tuesday at Fort Bliss, Texas. Last December, as she neared the end of her residency at Beth Israel Deaconess Medical Center in Boston, Hanna notified the Army that her renewed religious beliefs [she is a Coptic Christian] were now incompatible with military service.

I don’t know the woman or the details of her case, but it all sounds a little too convenient.

There’s a long history in the US of conscientious objectors serving as medics or performing alternative civilian service (along with some “absolutists” who refused to serve in any way.) Is it really too much to expect for Dr. Hanna to work in an Army field hospital in Iraq or Afghanistan? How about a military hospital in Germany? Or a VA hospital in Boston? Or a public clinic?

How decision support tools could address the malpractice “crisis”

published date
October 3rd, 2006 by

How decision support tools could address the malpractice “crisis”

I’m a big advocate of decision support tools like SimulConsult and Safemed, which can help doctors make better diagnoses and treatment decisions. A new analysis of closed malpractice cases provides powerful ammunition for more widespread use of such tools.

From the Boston Globe (Basic errors hurt patients):

Basic errors made by doctors, including tests ordered too late or not at all and failure to create follow-up plans, played a role in nearly 60 percent of cases in which patients were allegedly hurt by missed or delayed diagnoses, a study [in the Annals of Internal Medicine] found.
[M]ost claims involved several factors;… major ones included mistakes by doctors: failure to order appropriate diagnostic tests (100 cases); failure to create a proper follow-up plan (81); failure to obtain an adequate history or perform an adequate physical examination (76); and incorrect interpretation of tests (67).

The study’s lead author, Dr. Tejal K. Gandhi, director of patient safety at Brigham and Women’s Hospital , said the research shows that doctors could use more help in making decisions…

“I don’t want to say that it’s not the physician’s responsibility,” Gandhi said. “We think there could be tools to help physicians make these decisions better.”

When errors in diagnosis and treatment occur, people often conclude that doctors should know more about the disease in question. That’s part of the solution, but as Dr. Gandhi points out there also needs to be more focus on tools to help the doctor, not just piling more information on the doctor and encouraging the doctor to order more tests.

What do MDs need to know about statistics?

published date
September 19th, 2006 by

What do MDs need to know about statistics?

From the Boston Globe (Recommended for MDs: a grounding in statistics)

Doctors need at least a year’s study of statistics to understand the medical advances reported in scientific journals, according to a new report. And most of them don’t have it…

[Most schools provide six to eight weeks of statistics training.]

If doctors can’t interpret information about up-to-date techniques, they might use the information incorrectly or not use it at all, said the report’s author, Nicholas J. Horton, a statistics professor at Smith College…

But not all statisticians think doctors should learn their trade. Stephen Lagakos, a biostatistician at Harvard’s School of Public Health, said most doctors need to know only “the bottom line” of medical studies. He said busy clinicians should be able to use a study’s results without analyzing the statistics behind it.

Most doctors “take it as a given that the journal has done a responsible job in sorting out the bad studies and keeping the good ones,” he said.

I don’t think either of these profs have things quite right. All else being equal, it would be great for docs-to-be to become experts in stats. But expanding the amount of time devoted to statistics, as Horton suggests, would have to come at the expense of something else. I’m not sure it’s worth it.

Lagakos is a little too trusting of medical journals. It’s not just a matter of how well journals sort the good studies from the bad but how those studies are represented by others with a vested interest in getting doctors to act in certain ways, e.g., writing prescriptions for particular drugs.

I’d suggest devoting more of the existing six to eight week stats training to how to be a savvy customer of statistically-based messages. The class could be taught by someone with experience in pharmaceutical or medical device marketing. The syllabus should include titles such as How to Lie with Statistics that get students thinking more critically about what they are hearing.