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The CMG Voice

Reduced Hours in Residency Does Not Correlate with Reduced Quality of Care

Posted Wednesday, August 21, 2019 by Carl-Erich Kruse

Residents are doctors in training – recent medical school graduates who famously work long hours training towards their specialties. For many years, residents were required to work 100 hours a week. To many of us (not currently in a trial) a work week that long is nearly unfathomable. The reality is that residents need intensive training to gain exposure to the full breadth of their specialties before they can enter unsupervised practice. For a long time, the accepted thinking was that this meant 100 hour work weeks with 30+ hour shifts.

Reforms by the Accreditation Council for Graduate Medical Education (ACGME) to reduce the long hours of residents, begun nationally around 2003 (but with roots running twenty years earlier) started by capping a work week at 80 hours, with no individual shift running longer than 30 hours. The reforms were implemented in part to address resident errors due to fatigue. A measurable amount of opposition to the reforms, though, was based in concern about whether these doctors were receiving enough training in their residency. In effect, there was concern that newly minted doctors committed errors due to insufficient training. However, a recent study by the BMJ reveals that at large part of that concern has not been met.

The study compared outcomes of patients of doctors trained before the 2003 residency reforms, against those who trained after the 2003 reforms. For the metrics measured – thirty day mortality, thirty day readmission, and inpatient spending – the researchers found no statistically significant difference. Notably, the study focused on internal medicine doctors. Surgeons, for example, may be affected differently because the work restrictions may limit the amount of supervised procedures they perform.
The study was also limited in that it did not evaluate why there was no statistical difference; that is for future researchers to determine. The results of this study, nevertheless, are an important step towards further refining the residency program so that it balances the considerations of extensive, intensive instruction, against the health and fatigue of residents.

Read the report here:

Association of residency work hour reform with long term quality and costs of care of US physicians: observational study

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Transparency Matters

Posted Monday, August 19, 2019 by Carl-Erich Kruse

In a follow up to an investigative report, Ellen Gabler at the New York Times reports that North Carolina Children’s Hospital has suspended pediatric cardiac surgeries in its most complex cases. The University of North Carolina Health Care, which runs the hospital, further committed to publicly release mortality data and introduced initiatives to create an external advisory board of medical experts to recommend improvements, create a family advisory council to provide feedback to hospital leaders, and develop a new system for quality and safety reporting.

The University’s decision to release mortality data is notable for its long-term refusal to do so. The New York Times was in fact, according to the article, engaged in a year-long legal battle with the UNC Health Care system to release those statistics. The recent release comes quickly on the heels of the Times’s original investigative report. The statistics bear out the concerns expressed by hospital surgeons: that the hospitals mortality rates were alarmingly high. Hospital administrators, while denying any issues with patient care, blamed “difficult team dynamics” that they claimed had been resolved. The “team dynamic” language reflects the concerns expressed in a recent blog post here about surgical outcomes of unprofessional surgeons. The mortality statistics do not provide sufficient specificity to evaluate whether there exists a correlation at UNC consistent with the national averages reflected in the blog post.

The New York Times’ article inspired further changes by way of an investigation into the children’s hospital by the North Carolina secretary of health. A report is forthcoming.

The mortality rates released by UNC showed an overall mortality rate for pediatric heart surgery that was nearly double the national average (5.4% v. 2.8%) and a mortality rate for the most complex cases 3.5 times the national average (risk-adjusted average of 47.4% v. 14%).

Their hospital noted that the mortality rate for the past eleven months has fallen to 3%, after having managed personnel changes.

It could be said that the Times’ investigation helped force the hospital system’s hand. Perhaps the biggest takeaway is that transparency is giving patients the information they need and leading to improved quality of care. The article noted that in the US about 115 hospitals perform pediatric heart surgery; until UNC released these mortality statistics, it was one of the 25% of those hospitals that did not publish that data. The system committed to publishing these statistics annually online.

It seems frustrating that the infrastructural investment required by an investigative report, coupled with a year long legal battle, is what it took to force the system to actually make patient improvement changes to its system. That is more power than one or a number of medical malpractice lawsuits can bear, but demonstrate the difficulty in bringing about institutional change, even when peoples’ lives are at stake.

Read the Ms. Gabler’s followup piece here.

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Doctors – like many of us – have a hard time having hard conversations.

Posted Thursday, August 15, 2019 by Tyler Goldberg-Hoss

Recently the Seattle Times published an article about an Oregon physician’s own experience being diagnosed with a terminal illness.

The purpose of the article – and the purpose of Dr. Naito’s involvement, the doctor in question – was to shed light on the often “suboptimal” way doctors break grim news to patients. This is not an isolated incident, as an estimated 75% of patients in similar situations receive the bad news in such a “suboptimal” way.

In Dr. Naito’s case, he was able to piece together the news of his fatal diagnosis – stage 4 pancreatic cancer – from his own knowledge as a trained doctor, and snippets of conversations he would overhear outside the door of his clinic room.

That experience prompted Dr. Naito to devote a significant portion of what remained of his life to educating doctors on how they can improve the way they break such news to other patients.

This is not the only area in which doctors can be “suboptimal” in having a conversation with a patient. Certainly, when the doctor (or hospital) commits an error and causes harm, it is much easier to avoid any discussion about the cause of the unexpectedly bad outcome, or leave it to administration or lower level care providers to talk with the patient.

Similarly, a fatal diagnosis can be a subject that is very difficult to approach for doctors who perhaps have not had a lot of training in how to do it. One problem can be failing to take into account how emotionally overwhelming it must be for a patient to hear such news. Another problem can occur when doctors use medical jargon they are more familiar with, instead of plain language the patient will better understand.

This can be problematic, particularly when the patient is misled about her diagnosis, and makes health care decisions with incorrect assumptions. The article also cited a 2016 study that found that just 5% of cancer patients understood their prognoses well enough to make informed decisions about the medical care they wanted.

This may not ultimately change the outcome in a patient with a terminal disease, but it can certainly effect what treatment they get. For example, a patient may elect to undergo chemotherapy with serious side effects, thinking that it gives her a better chance for a cure than it really does. As a result, she suffer through the chemotherapy and side effects for a marginal increase in life expectancy. Had she known about the limited upside of the treatment, the patient may have elected to receive only palliative care, and enjoyed what was left of her life.

Dr. Naito is hopeful doctors will get better at having these difficult conversations, so that future patients will avoid the experience he had when he was “told” of his terminal illness. I imagine most doctors themselves would like to get better at it too.

You can read the Seattle Times article here:

Oregon doctor with grim diagnosis is sharing a final message about how physicians break bad news

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Read Your Notes

Posted Monday, July 29, 2019 by Carl-Erich Kruse

All of our doctors are taking notes during our visits. The thing is, their notes are often times your notes too. When our referrals are made to specialists, our doctors are sharing the notes for our medical visits. It is how providers can improve on continuity of care: that concerning conditions warranting referral are being followed up on and tracked.

Your providers’ notes contain a wealth of information and impressions that can be extremely helpful to us as well so we as consumers can stay on top of our own health. Reading our doctors’ notes can also help identify errors in the medical record and afford opportunities to correct the record. That in and of itself can help avoid devastating outcomes.

The Health Insurance Portability and Accountability Act, HIPAA, is federal law that allows you the patient to review all of your medical records. The Health Information Technology for Economic and Clinical Health Act (“HITECH”) is another federal law that lets you request and receive copies of your medical records in digital format for a minimal cost. To be clear, your visit notes and medical records consist of far more than after visit summaries we all receive.

As Kaiser Health News reports, accessing your own health care records can help reinforce concerns identified by your providers, and lead to an overall improvement in healthcare. As medicine continues to embrace the collaborative care model – the patient/provider shared decision-making model – this is seen as widely beneficial to the public. Our medical records have a lot of information that to a layperson may be hard to understand, but all of the terms are readily searchable online. Open Notes, a research project in Boston, is encouraging doctors sharing their notes and advocating for easier, more streamlined access around the country.

Educated patients can be more mindful during their visits and involved in the share decision-making process. This can help providers focus in on patient complaints for latent progressive issues. Doctors, after all, are busy people, and do not have the time to pour over our notes, lab results, test results, and referral notes. Time and time again we sit through depositions where providers explain they have the time to perform a cursory glance at these results, and unless something jumps out at them, do not have reason to take action.

One barrier millions of patients are having to overcome is the often convoluted, difficult process to request records from hospital systems. Washington’s law, for example, requires they provide records within fifteen days of a patient request, but gives little teeth to any enforcement process. The truth is some hospitals, clinics and providers are simply better than others at responding within the timeframe. It can be a frustrating process, but can help shed light on how your provider is addressing your complaints. From our perspective, while there is an aspect of “peering over your doctor’s shoulder” this effort for greater transparency has to no doubt lead to better patient outcomes as less missed diagnoses.

Read the Kaiser Health News article here.

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Unprofessional Surgeons have more Surgical Complications

Posted Monday, July 22, 2019 by Carl-Erich Kruse

A surgeon is more than just a steady hand. An article published recently in The Journal of the American Medical Association (“JAMA”) Surgery finds a correlation between surgeons’ (un)professional behavior and surgical complications. The authors set out to investigate whether patients of surgeons with a higher rate of coworker reports about unprofessional behavior experienced a higher rate of complications than surgeons with no such reports. They concluded that indeed there was a significant correlation.

The authors reviewed 13,653 surgeries performed on adults by 202 surgeons at two “geographically diverse academic medical centers” from 2012 through 2016. They reviewed the professional background for the 202 surgeons for coworker complaints of unprofessional conduct in the thirty-six months preceding the offending operation. The authors found that the complication rate was 14.3% higher for surgeons with one to three reports of unprofessional conduct and 11.9% higher for surgeons with more than four reports than for those with zero reports.

If we extrapolate those outcomes to all surgeries performed nationwide, the difference is hundreds of thousands of complications each year. What does the study mean, though, for improving those outcomes? The article does not address causation. However, hospitals should, in theory, already have systems in place to address personnel issues. And many of the reported behaviors have corollaries with hostile work environments. The authors did not distinguish the character of unprofessional conduct; the general term was meant to encompass things such as reports of yelling at co-workers, throwing of instruments, or violating hospital policies. For a patient’s surgery, each of these “work environments” is reduced to that patient’s individual experience. After all, a successful surgery requires good communication, respect, and situational awareness. Not clearly explained or addressed in the article is that perhaps these hostile environments interfere with the smooth process of a successful surgery, by putting up barriers in communication or situational awareness, or even simply distracting the staff in the room. This area may be fodder for further research.

From a patient’s perspective, there is frustratingly little we can do to research our surgeon’s background. Washington law, for example, protects as privileged all hospital records in a doctor’s file related to quality improvement. This likely includes individual reports by hospital staff of unprofessional incidents. Where we have a choice, as patients we are therefore tasked with using our gut instinct. For hospitals, however, correlating unprofessional incidents with bad patient outcomes should spur greater urgency for intervention.

Read the original report here.

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