Doctors are overwhelmed with data. They spend 12% of their time looking up clinical data when they could be seeing patients and still information gets missed. In fact, the IOM has identified untimely access to clinical data as a leading contributor to the 3rd leading cause of death in the US: medical errors. Existing information systems and electronic medical records are better optimized for billing and documentation than they
are for making care safer. There has to be a better way.
OK, so there are a lot of doctors: PhDs, JDs, DDS. For the sake of argument, I’m talking about MDs here. Let me start by explaining night float.
Night float is an interesting rotation during residency when most people who are working during the day leave their hospital and their patient’s care in your hands. It is alternately some of the quietest times during residency as patients drift off to sleep and some of the most hectic as in when a surge of patients finally arrive from their ambulance- or helicopter-assisted journey across the state. Night float, or “the night shift” arose out of a recognition that sleepy interns having worked 30-hours straight sometimes do not make the best decisions or confuse their lefts and their rights.
The 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk introduced a new risk assessment calculator based on aggregate data from several cohorts. According to these guidelines, a patient’s risk according to this algorithm is critical in determining if a cholesterol-lowering statin should be prescribed. Initially, this calculator was available only through a somewhat onerous Excel spreadsheet. Moreover, this was nearly impossible to access through mobile phones, a preferred modality. Continue reading
Much ink has already been spilled about the impending primary care crisis. Fifty years ago, 50% of physicians practiced primary care. Now, it is only 30% of them and many of those primary care physicians (PCPs) are approaching retirement. According to a recent Senate report we are short roughly 16,000 PCPs already and this number is expected to grow. Wait times have been steadily increasing and it is becoming harder and harder to access the quality PCP that we all need. It would seem that physician-provided primary care is dying.
In truth, the PCP is already dead. Step inside any PCP office for a moment and reflect on how many substantive interactions there are throughout the day. The average PCP spends less than 15 minutes with each patient, leaving 5 minutes for your history, 5 (generous) minutes for your physical, and 5 minutes for assessment / wrap-up. Somehow, these brief interactions are expected to do some of the most challenging work a physician faces: educating the patient and promoting healthy behaviors. A pediatrician I spent time with during medical school often joked that he needed roller skates to keep up with the patient volume. Something like these babies might’ve helped.
Continue reading The Death and Rebirth of Primary Care on the Symcat blog.
Early in medical school, I was involved in the care of Ted, who could have been my grandfather. At 76 he was as spry as any of the patients on the ward and always welcomed me with a “morning, Doc!” He was admitted because he was having concerning chest pain several times a week. Opening and closing 2.8 billion times throughout his life, his heart valves had gradually become hard and inflexible preventing blood from leaving at its usual rate. Now, it was risking his life. He had several treatment options available to him: valve replacement through open-heart surgery, a new minimally-invasive procedure where they snaked a new valve through the body’s blood vessels and into the heart, or just taking medications to help with his symptoms. It was my job to help Ted figure out which option was best for him.
Continued reading The Real Problem with Physician Decision Support on the Symcat blog.
Each year, half a million patients present to emergency departments in the US with acute vestibular syndrome (AVS) characterized by vertigo lasting more than 24 hours. Though this is frequently caused by something benign such as a self-limited viral infection, it may also indicate a more severe condition such as stroke of the posterior circulation. Unfortunately, MRI can miss strokes when obtained early in the disease course meaning half of those with with posterior strokes are inappropriately sent home from the ER. Continue reading
Tracheostomy is an unpleasant, but effective means for transitioning patients off ventilatory support after prolonged periods of respiratory failure following cardiac surgery. There is, however, a perceived risk of patients getting infections of the surgical, sternal wound if tracheostomy is performed too early. This perceived risk means patients are often delayed in tracheostomy, including the benefits of ability to speak, reduced mortality, reduced ICU stay, and reduced delirium until the surgical wound is felt no longer at risk. Continue reading
Though in some ways replaced by ultrasound technology, cardiac auscultation–using a stethoscope to listen to a patient’s heart–remains an important screening modality for recognizing heart disease. Auscultation serves as a cost-effective screening tool for heart disease and is of particular importance in several clinical scenarios. Less emphasis has been placed on training US clinicians in auscultation, however, making this something of a “lost art.” This may delay a patient’s diagnosis of heart disease. Continue reading