A lack of standardized policies and an increasingly litigious culture have combined to make doctors wary of abandonment claims and medical malpractice lawsuits, according to Boston-area healthcare lawyers. As a result, the lawyers say that in recent years they have fielded more inquiries from doctors and healthcare organizations about the best way to terminate a doctor-patient relationship. While statistics on patient "firings" are difficult to track, Boston practitioners say the numbers are trending upward.
When most of us think of nurses, we picture a caregiver at the bedside, taking the blood pressure of a patient or giving them the medication they need to get well. We don't picture them in the back corner of an office, surrounded by mounds of patient charts. But a new study--commissioned by the Robert Wood Johnson Foundation--shows that nurses are spending more time on paperwork and less time caring for patients.
"Nurses spent 60% of their time on the computer, or on the paper trail," says Susan Coombes, MA, CHC, manager of regulatory compliance for Oregon Health & Science University. The result is less time at the bedside, putting patients at risk and our efforts to improve quality in jeopardy.
Nurses are essential to our quality improvement efforts. They're on the front line--spending more time with patients than any other member of the medical staff. They dispense medication, take vitals, and provide that hand to hold when a patient needs a little TLC. They develop relationships with their patients and can often spot a change in condition just by looking in a patient's eyes or hearing strain in his or her voice. But standards set by regulatory agencies are taking nurses away from the bedside, where they are less likely to notice these things.
Everyday tasks that once took minutes are now taking nurses double and triple the time, says Deborah Eldredge, PhD, RN, director of evidence-based practice and assistant professor at the OHSU School of Nursing. Not only does a nurse have to take a patient's vitals, but now has to document that the vitals were taken, and verify that the vital check was documented.
"If we're having to do that every two hours on every four patients, when are we supposed to do the other things that nurses do--teaching, counseling, and making people feel better?" Eldredge asks.
This isn't to say that nurses aren't strong believers in providing quality care--they are. The desire to provide patients with the care and comfort they need is what brought them to this profession in the first place. But they are humans, and we can only ask so much of them.
"New demands in the arena of patient safety are already running nurses out of time in patient care," says Coombes. "These aren't the wrong things, but there are too many things."
The RWJF study was released last week by the Center for Studying Health System Change. Many of its findings were things that we already know. But perhaps it included ideas we haven't considered: As our nursing population shrinks and demands grow, we need to think twice about the load we're putting on our nurses and how much care we're allowing them to give.
This doesn't mean that we need to eliminate documentation efforts, or that our efforts are doomed to fail, Eldredge says. Documentation requirements are here to stay--and there are probably more on the way. To get the most out of our workforce without compromising care, we have to get smarter about our processes.
Instead of going from room to room checking patients who are at risk for pressure ulcers, then starting all over again to check those patients who are at risk for falls, Eldredge says there's opportunity to more efficiently address related risk and care needs. "It's all about work redesign," Eldredge says. "Think about what is going to make the biggest difference. You want a nurse's day to be as organized as possible."
Part of that organization is training, Coombes says. Nurse managers often get so bogged down in the "must dos" of their daily shift that they don't have the time to spend training nurses on how to do more with less.
"Middle management in healthcare takes a beating because they have to make everything happen...they get pulled away too much," Coombes says. "It's been our goal to get the managers back to the bedside and put their hands around practice."
Getting your nurse managers back into patient care can go a long way to solving a unit's care issues, Eldredge says.
"If we could free up nurse managers to be at the bedside to address patient needs and mentor new nurses, we'd be much better able to identify system problems."
For many medical students, March Madness has nothing to do with basketball. This is the time of year they find out which residency program accepted them, effectively determining the specialty they'll practice for years to come.
This year's "match day" was last Thursday, and medical students weren't the only ones following the results. Facilities concerned about physician shortages look to residency placements for indications about upcoming recruitment challenges and investment opportunities. We hear often of the projected shortage of 200,000 physicians by 2020, but that number doesn't adequately address the nuance of the problem. Some specialties are already experiencing shortages and have been for several years. Others may see significant growth for many years to come.
In the spirit of March Madness, here's a brief ranking of how each specialty will fare between now and 2020. Fill out your brackets accordingly:
(1) Dermatology. Most specialties that offer high salaries also have rigorous schedules with full call, and specialties with flexible schedules that appeal to "lifestyle" physicians often lag behind in compensation. But with median salaries around $400,000, dermatology offers both, and that's what makes this specialty a physician favorite.
(2-3) Plastic surgery/otolaryngology. As this New York Times article notes, medical students with the highest medical-board scores are gravitating toward "appearance-related" specialties, which have everything today's physicians are looking for: high patient demand (thanks to a looks-obsessed culture), high pay, and options for flexible and autonomous scheduling.
(4-5) Radiology/anesthesiology. Though these specialties have seen or will see shortages, they pay fairly well--a factor that is crucial when competing for a limited number of applicants--and are able to use nonphysicians (i.e., CRNAs) and technology (think teleradiology) to treat more patients with fewer physicians.
(6) Ophthalmology. With a median compensation of about $300,000, ophthalmology is in the middle of the pack on "offense" (i.e., salaries), but it makes up for that with a strong defense (i.e., opportunities for work-life balance).
(7) Cardiology. Invasive cardiologists are among the highest-earning specialists. Though hit recently by reimbursement cuts, the specialty is a big revenue generator for hospitals, which will continue to invest in this area. The problem: The aging population is going to send the need for cardiac services soaring, and facilities will need more cardiologists to keep up.
(8-11) Gastroenterology/orthopedic surgery/neurology/oncology. The middle of the bracket can be analyzed with two words: Baby boomers. There just may not be enough physicians to perform all of the hip replacements, colonoscopies, and other procedures that this generation is going to need as it enters its Medicare-eligible stage. These specialties don't offer the same lifestyle benefits as the top seeds and will be competing with each other for physicians. It may come down to a salary race.
(12) Hospitalists. Given the unique practice style and the documented benefits of hospitalists, these physicians earned their own bid on the bracket, separate from the rest of primary care. They may not be highly compensated--median levels fall below $200,000--but physicians are drawn to the controllable work schedule. Many internists prefer working as hospitalists, and the model is now spreading to other specialties.
(13) OB/GYN. High malpractice costs and call coverage are a major problem, but the laborist model of practice, which is similar to a hospitalist arrangement, may resolve those issues and draw physicians to the specialty.
(14) Emergency medicine. These physicians staff America's overcrowded emergency rooms, and their reward is a crummy payer mix and a shortage of specialists willing to take call. On the other hand, the number of emergency medicine positions increased in this year's match day, and federally-driven healthcare reform efforts could change everything and make this specialty a bracket buster.
(15) Primary care. These (family medicine, internal medicine, and pediatrics) are perennial fan favorites and could be your Cinderella specialties. Low compensation levels have been driving students away from primary care for years. But these doctors are the gatekeepers of healthcare, and most industry reformers realize their value. An influx of female physicians and international medical graduates may help primary care make a comeback, and as is the case with emergency medicine, healthcare reform could change everything.
(16) Geriatrics. How does a patient population made up almost entirely of Medicare beneficiaries sound to you? Probably not good, especially considering the upcoming 10% reimbursement reduction. Geriatricians are already in one of the lowest-paid specialties, and medical students aren't exactly clamoring to get in. Maybe they just aren't aware that geriatricians have among the highest career satisfaction levels of all physicians.
I should note that, if this is anything like my NCAA March Madness bracket, the final results will be very different from my initial predictions, so take them with a grain of salt. A lot can change in 12 years--an underdog or two may prevail and a favorite may fall--and everyone's predictions are different. What does your bracket look like?
Donna Lemmert, infection control coordinator, and Gary Fritz, laboratory manager at Baltimore Washington Medical Center in Glen Burnie, MD, talk about how rapid molecular testing of high risk patients has helped reduce patient-to-patient transmission of MRSA.
Kaiser Permanente became the first healthcare provider in Oregon to issue a public report on the quality of care at its outpatient medical offices. The results, which compare clinics on nine quality measures, are available online. The reports do not identify ratings for individual medical providers. The Oakland, Calif.-based health system has posted clinic-by-clinic quality results about one year ahead of a regional effort to publish quality information about Oregon medical offices.
Washington Hospital in Fremont was fined $25,000 by the California Department of Public Health because a heart patient treated there last year was given the wrong drugs and died. The 87-year-old patient was mistakenly given another patient's methadone and desipramine--often used to treat drug addicts--along with two other incorrect medications. Washington Hospital was one of 11 in California cited and fined because of errors that caused death or injury to patients.
A small, but worrisome number of facelift patients became infected with the antibiotic-resistant staph infection known as MRSA, a new study reports. About one half of 1 percent of people undergoing facelifts developed the so-called "superbug" methicillin-resistant Staphylococcus aureus infection, doctors from Lennox Hill-Manhattan Eye, Ear, and Throat Hospital in New York City reported.
Eliza Coffee Memorial Hospital is leading the Southeast in reducing the number of urinary tract infections among hospital patients. Commonly, the catherization process has been cited as the reason most people develop infections while in a healthcare facility. Employees at ECM have developed a procedure that reduces the rate of infection by more than half.
Doctors who refer a large bulk of their business to their doctor-owned ambulatory surgery centers were more likely to send well-insured patients to the centers while referring lower-paying Medicaid patients to hospital outpatient departments, according to a study of two Pennsylvania healthcare markets published in the March 18 edition of Health Affairs. Physician-owners with high rates of referrals to their doctor-owned ASCs directed Medicaid patients to hospital outpatient units at a rate about 36 percentage points higher than they directed patients with higher-paying private insurance to outpatient departments, the authors found.
Ohio State University Medical Center made it a bit easier to find hospital data that consumers would be interested in. The hospital put this information--most of which it already reports to the federal government--on its Web site. The hospital is the first in the Columbus area to post this information online. The other three hospital systems said that they plan to do so in the coming months. The goal, OSU officials say, is to give consumers more information so they can make better choices about where they get their healthcare.
