Mexico's violent drug war is finding its way into the nation's hospitals, shaking the healthcare system and leaving workers fearing for their lives while trying to save the lives of others. Doctors feel particularly vulnerable: When they leave their offices, they say they face the risk of being kidnapped and held for ransom, as about two dozen physicians have been in the last few years.
Although the Web is awash with sites eager to give consumers information regarding physicians, online doctor rating systems have a shocking lack of useful information, according to this commentary published on Slate.com.
The phrase "hallway medicine" doesn't exactly invoke images of a quality care environment. Not to me, at least. Nevertheless, some providers are beginning to view the notion of shifting emergency department patients to inpatient hallways as preferable to the alternative.
A study at Stony Brook (NY) University Medical Center found that no harm was caused by transferring ED patients to upper-floor hallways when they were ready for admission. Presented at a recent American College of Emergency Physicians meeting in Chicago, the study concluded that the strategy is a way to make the entire hospital responsible for emergency patient care and thus relieve overcrowding in the ED.
I confess I have mixed feeling on this one. The Associated Press quoted the study's lead author, Peter Viccellio, MD, as saying the findings mark "yet another battle cry for hospitals to get off their duffs and stop stacking people knee-deep in the emergency department." Well... yes... crowded emergency departments are a significant problem, to say the least. Boarding patients in the ED because there are no inpatient beds to be had is not an acceptable alternative; in fact, a 2007 ACEP survey of emergency physicians found that 13% of them had experienced patients dying because they were boarded in the ED even after they were admitted to the hospital. Viccellio, Stony Brook's ED clinical director, told the AP that on busy days, the ED would "grind to a halt" before his hospital began using hallways. And when it comes to finding solutions, healthcare certainly needs all the innovative thinking it can get.
But sticking patients in hallways as a matter of policy? Plenty of ED caregivers would probably tell me that they safely provide hallway care all the time and that I should get over it. But what about the privacy implications of hallway medicine? Or the safety issues? Or fire codes? Or the basic question of who cares for these patients?
Ultimately, I just have trouble accepting the premise that ED boarding and hallway medicine are the only alternatives. Our HealthLeadersmagazine cover story this past January looked at the steps some hospitals are taking to fix the problems in their emergency departments. In Mississippi, for instance, a 580-staffed-bed hospital developed a "rapid-admit" unit to quickly move patients out of the ED for preadmission procedures like IV insertion. Flagging ED tests as high-priority helped ease lab bottlenecks that exacerbated overcrowding. Other organizations addressed their triage processes to increase efficiency and weed out lower-level primary care cases to get people in and out more quickly and free up space. In short, there are hospitals out there that have found solutions that don't involve ED boarding or inpatient hallways.
That said, I realize that plenty of major ED overcrowding issues can't be solved just by tweaking some triage processes. If half of the ED's beds are filled with holds for the ICU or other areas of the hospital, how is that the ED's fault? And if patients are already receiving care in an ED hallway, are they any less safe in a hallway two floors up?
I'd like to hear from you on this—how is your hospital addressing the issue of ED overcrowding? Do you see hallway medicine as a viable alternative? Beyond the choice between boarding in the ED and inpatient hallway care, what is the best third option? Send me an e-mail—I'd love to hear your thoughts.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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Despite transparency initiatives and pushes for greater healthcare consumerism, most patients still rely on word of mouth and physician referrals to pick a new healthcare provider, according to a study by the Center for Studying Health System Change. A 2007 study by the Center found few American adults engaged in active shopping or considered price or quality information when choosing specialists or facilities for medical procedures.
An ambitious plan by Harvard Vanguard Medical Associates attempts to ease physician shortages, and reduce patient and doctor dissatisfaction over constantly feeling rushed during appointments. Through the plan, physicians see patients only in groups, formally called shared medical appointments. A Harvard Vanguard survey found that 77% of patients who had attended one said they would do so again.
Competitive compensation packages and flexible practice structures are essential to attract today's physician. To be successful, leaders must create a practice that appeals to the career goals and practice styles of a changing physician work force.
But bringing in quality physicians is an increasingly difficult and competitive task. With a dwindling pool of physicians to choose from, standing out from competitors is more important than ever.
To be successful, physician practices must research and use strategic marketing data, develop competitive recruitment offers, learn what practice structures attract today's physicians, and have the ability to compare the costs and benefits of various recruitment strategies.
Physician practice leaders also must work with physician and administrative partners to align recruitment with organizational initiatives, culture, and growth strategies.
Although compensation is usually the first thing on administrators' minds when they think about how to attract physicians, money is not everything to the younger generation of physicians. Practice culture is very important as well.
In regard to compensation, practices should consider using nonproductivity-related goals to establish bonus criteria like participation in physician leadership activities and patient satisfaction scores.
Bonuses are a long-established part of many compensation packages as well, but it's important to look at the risks they pose to the organization.
Benefits should go beyond simple compensation issues. Administrators should consider what they are offering compared to competitors as well as look past traditional perks. Paying for additional schooling or offering sabbaticals after a certain length of time spent working for the practice are possibilities.
This article was adapted from one that originally ran in the December 2008 issue ofThe Doctor's Office, a HealthLeaders Media publication.
When I used to hear the term "disruptive physician," I pictured an angry doctor berating a nurse for no reason or, in extreme cases, a surgeon throwing a scalpel across an operating room.
It is, after all, the image invoked in articles like the one about disruptive doctors in this week's New York Times.
But that was before I spoke with Gil Mileikowsky. I interviewed the California-based obstetrician a couple of months ago while researching physician whistleblower candidates for our upcoming feature about 20 people who make healthcare better, and it has since made me think twice when I hear a physician called disruptive.
Like a lot of whistleblowers, Mileikowsky paid a high price for attempting to expose a flaw in the healthcare system. Very shortly after bringing up what he perceived to be systemic quality issues at his hospital and agreeing to serve as an expert witness in a related trial, he received the "disruptive" label and was informed by the hospital CEO that he would be escorted by security guards while on hospital grounds.
It's a familiar story to physician whistleblowers, and the disruptive label can, when abused, be a potentially powerful weapon for hospital administrators looking for a little leverage or, in some cases, revenge.
Not that there aren't plenty of disruptive doctors. As the New York Times piece points out, recent research suggests a wide-spread problem. A survey of healthcare workers from 2004 to 2007 found that 67% thought there was a link between disruptive behavior and medical mistakes, and 18% knew of a mistake that occurred because of an "obnoxious" doctor. Another survey by the Institute for Safe Medication Practices, found that 40% of hospital staff members reported withholding their concerns about orders for medication that appeared to be incorrect because of doctor intimidation. As a result, 7% said they contributed to a medication error.
Physicians who are truly disruptive put patients in danger, are a drain on an organization, and need to be dealt with. But given the term's ambiguity and potential for abuse, are hospital administrators really the best enforcers?
This seems like a problem ideally suited for physician leadership, whether from a medical director or through peer-to-peer physician intervention. If physicians are the first line of defense against disruptive peers, it is less likely to be a wedge issue between physicians and hospital administrators.
The Joint Commission's new standard requiring accredited institutions to address disruptive behavior is a step in the right direction because it formalizes the process, but it only vaguely calls for a code of conduct and processes for dealing with "disruptive and inappropriate behaviors," without a clear indication of what that means. And perhaps more importantly, it doesn't address physician involvement in the process.
The hospital is still free to define disruptive behavior as it pleases, and that can leave good physicians susceptible to unfair punishment.
Everyone's ultimate goal is to root out the doctors that are causing problems for patients and other providers. But to do that we need a much clearer definition of disruptive behavior, and physicians need to be involved in defining it.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.Note: You can sign up to receive HealthLeaders Media PhysicianLeaders, a free weekly e-newsletter that features the top physician business headlines of the week from leading news sources.
When I began performing the laparoscopic adjustable gastric band (LAGB) procedure in 2003, we held monthly three-hour educational seminars for prospective patients in order to explain risks and benefits, to discuss qualifications, insurance, and alternatives, and to answer questions.
Screening and educating potential patients about surgical procedures is essential to ensure that those who wish to proceed are eligible and informed. Clinical practice guidelines published this year indicate that prior to bariatric surgeries, patients should receive educational materials and access to preoperative educational sessions.
But these seminars were frustrating for several reasons. Attendance at each seminar was about 80 to 100 people, so the room quickly became uncomfortably warm and crowded. We often did not have enough bariatric chairs to accommodate everyone. Some people arrived late and others left early, disrupting the presentation. Often one person would monopolize the floor with questions that others might consider too personal. Several might be too embarrassed to ask questions at all. The lack of privacy was a huge issue. Patients absorbed maybe 20% of what we told them.
The results were equally uninspiring; a mere 10% of attendees actually pursued the surgery. It was a highly inefficient process and I felt like I was spinning my wheels. I had to find a better way to educate and screen prospective patients.
I discontinued the seminars and in 2005 and implemented a Web-based patient education. Prospective patients instead were given a "prescription" access code to log onto a 30-minute Web-based multimedia program created by Emmi Solutions, which covers pre-, peri- and postoperative care, as well as risks, benefits, and alternatives to LAGB surgery.
The beauty of this interactive patient education tool is that people can view it at home, as often as desired, and they can share it with family and friends. They can pause, rewind, and type in questions for me to address with them later, in private. Patients can also print out a copy of the presentation for future reference or bring it with them to their next consultation, ensuring that they have a baseline of knowledge. In addition, my staff and I are able to track whether a prospective patient has viewed the information, as the entire patient viewing process is recorded and archived in a secure database.
The benefits of this approach are manifold. My mandatory one-on-one preoperative meeting with each patient (which ensures that he/she fully understands the surgery and risks) used to take two hours. The Web program cut that time down to one hour because they came to me with a much better understanding of the procedure than they did after attending a seminar.
Our surveys show that patients are thrilled; they appreciate how informative it is, and the convenience and privacy of watching from home. In fact, they often refer other patients to my practice in part because of this initiative. My staff is happier, too. They no longer need to answer as many clinical questions and therefore can more efficiently screen out patients who are ineligible for the surgery, either for medical reasons (10 -15%) or due to insurance coverage (30%-40%).
Best of all, virtually all eligible patients who view the Web program now elect to undergo the procedure, increasing the number of surgeries I perform each year. In 2004, prior to implementing the Web-based program, I performed 198 surgeries. In 2007 I performed 284 surgeries, a 43% increase. Thus, the program has greatly improved our bottom line.
Charles E. Morton, III, MD, PC, FACS, is medical director of Bariatric Services at Baptist Hospital Metabolic Surgery Center in Nashville TN.
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Barack Obama's incoming administration has begun to draw on the high-tech organizational tools that helped get him elected to lay the groundwork for an attempt to restructure the U.S. healthcare system. Thomas A. Daschle, Obama's point person on healthcare, launched an effort to create political momentum in a conference call with 1,000 invited supporters culled from 10,000 who had expressed interest in health issues, promising it would be the first of many opportunities for Americans to weigh in. The healthcare mobilization will also include online videos, blogs, and e-mail alerts as well as traditional public forums.
Sharpening the emerging debate over how to reshape the country's healthcare system, America's Health Insurance Plans has unveiled a proposal for covering all Americans in a more centralized insurance market. The AHIP plan would require all Americans to get coverage. In exchange, insurers would agree to longtime demands from consumer advocates that they no longer reject people with preexisting medical conditions. But consumer groups fear that a mandate requiring Americans to get insurance could force people to buy unaffordable coverage unless state or federal authorities can regulate how much insurers charge.
