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Opinion: Let's Talk About Residents' Hours – And Their 'Scut' Work Too

By Sefira Bell-Masterson, Dr. Lakshman Swamy and Dr. Christopher Worsham

A few things in medical education have changed in the past 100 years.

A century ago, for instance, resident physicians-in-training literally lived on hospital premises.

They received room and board but no other compensation. They routinely performed any task related to patient care, ranging from transporting patients to the operating room to performing their surgeries.

Clearly, things have changed. But what hasn’t changed is how medical residents are used for any task that needs to be done during a patient’s hospital stay.

Today, residents are expected to learn medicine, care for patients, and improve our health care system — often in addition to teaching and research. All this needs to be done within a limited number of nationally regulated duty hours, now the subject of an ongoing and increasingly controversial conversation in the medical community since restrictions were put in place in 2003 and 2011.

Over the past decade, there has been much debate about the benefits and drawbacks of duty hour restrictions, yet prior research into this topic has shown mixed results. Earlier this month, however, researchers published results of a first-of-its-kind randomized trial (the FIRST Trial) of 117 surgical residency programs across the country. The study’s authors concluded that there was no difference for patients or their doctors’ satisfaction whether residents worked under current duty hour restrictions or under more flexible rules. Results of a similar trial performed on medical residents (the iCOMPARETrial) are expected later this year.

Adil Yunis, a resident in internal medicine at Boston Medical Center, is working with hospital executives to improve the health care system for his patients and his fellow residents.

Adil Yunis, a resident in internal medicine at Boston Medical Center, is working with hospital executives to improve the health care system for his patients and his fellow residents. (Courtesy)

As residents ourselves, we believe the duty hours conversation has missed a major point: Though our hours are being limited, what we actually do during these hours is not.

There has been a great focus on the number of hours worked, but silence about the actual work done.

Erica, a resident in obstetrics and gynecology in Delaware, routinely runs her own lab tests in the office. Karl, a pediatrics resident in New York, often spends valuable time in the room with a child and her parents laboriously copying information from her medical record to fill out school forms.

Adil Yunis, an internal medicine resident in Boston, will spend 30 minutes on the phone trying to get a cardiology appointment for his patient who just had a heart attack.

These tasks (all real, but with two last names withheld ) are examples of what many residents call “scut.” Continue reading

Opinion: American-Muslim Doctor Reflects On Bigotry At Some Top Hospitals, And Beyond

By Altaf Saadi, M.D.
Guest Contributor

Recently, the wife of a prominent Boston businessman — one of my many wealthy, white patients at Massachusetts General Hospital — greeted me this way: “So what foreign medical school did you go to anyway?”

For background, I’m a petite, Middle Eastern young woman with a headscarf, and I’m guessing I do not resemble her vision of what a doctor “should” look like. That image is probably taller, whiter, male and not Muslim.

My answer (in perfect, unaccented English) to her question about where I was trained? “Harvard Medical School.” After that, her lips remained pursed shut for the rest of our encounter.

As the daughter of Iraqi and Iranian immigrants, such interactions unfortunately have been common for me and my family members since we moved to America weeks before 9/11. When former President Bush declared war on Iraq the following year, for example, my sister and I heard classmates scream, “Go back to your country!” from their pickup truck on our walk home from high school.

I thought that attending college and medical school at Yale and Harvard, respectively, would be my golden ticket to America’s meritocratic dream, that my prestigious diplomas would shield me from future experiences with racism and bigotry. As a neurology medical resident in “liberal” Boston, (and working at a hospital ranked No. 1 by U.S. News & World Report) I also thought that I would be judged based on my medical acumen, not by the color of my skin or the scarf I wear on my head. But I was wrong.

Dr. Altaf Saadi (Courtesy of the author)

Dr. Altaf Saadi (Courtesy of the author)

Another time in the hospital, a male patient told me that his religion is superior to mine. While I was listening to his lungs to help in the management of his shortness of breath, he added, “Why do you wear that thing on your head anyway?” Despite his abrasive behavior, I politely informed him of his treatment plan and told him that I am praying for his speedy recovery.

Another day,  an 80-year old patient with dementia began hitting me on the head when I checked in on her for my daily visit. Pointing to my headscarf, she said, “I don’t want someone with that taking care of me.” Despite her mental condition, the racism still stung as I continued to strive to provide her the best care possible.

My experiences are not isolated. A recent study in the American Journal of Bioethics found that 24 percent of Muslim physicians have experienced religious discrimination in the workplace.

This election year has made it harder to be a Muslim in America. Republican front-runner Donald Trump has advocated for registering Muslims inside the United States and banning those of us who reside abroad. Unfortunately, the majority of Republican Party members agree with him and the number of hate crimes against Muslims have tripled in recent weeks. Yet, I also recognize that Muslims are just America’s newest “outsiders.” Throughout our history, Catholics, Irish, Italians, women, African-Americans, Jews, Latinos and gays have all been targets of nativist fear-mongering. Many of these groups still face significant prejudice today, and hospitals are not immune from such discrimination, whether implicit or explicit.

When I was a third-year medical student, it appeared to me that the pediatric residents and attending physicians would spend extra time caring for the white infants and children during morning rounds. The two African-American babies and one Arab infant admitted to the inpatient pediatrics service at the time were never “oohed and aahed” at and received noticeably less attention. “Have you noticed that only the white children are called ‘cute’?” I asked my friend after our third day on the pediatrics rotation. My friend, an African-American medical student, had his own grievance. He had overheard a doctor refer to an African-American father as an “angry black man.” “I don’t understand,” my friend said. “His daughter is dying, he is upset, and has questions. He’s not asking any more questions than the other parents.”

Our observations were also not isolated incidents. Multiple peer-reviewed studies have shown that physicians unconsciously prefer and spend more time with white patients than African-American ones.

I also recall the occasional episode of overt racism in the hospital. One surgeon — prominent and stern in his crisp white coat — said the following about a Hispanic patient who was coming to have her melanoma examined for excision: “I can’t believe these people! They have been here for a decade, can’t bother to learn English, and we’re stuck waiting for an interpreter.”

But the episodes of implicit racism have been more commonplace. Continue reading

Mapping Antibiotic Resistance: Know The Germs In Your Neighborhood

By Dr. David Scales

You may have heard about Daniel Fells, the tight end on the New York Giants who almost lost his foot due to a drug-resistant infection. You’ve heard about drug resistant infections like Fells’ because dire reports about “the end of antibiotics” are all over, but maybe you want to know if resistant germs are common near you.

Unfortunately, you’re out of luck. While your hospital probably collects that data, they probably won’t share it with you.

John Brownstein, an associate professor at Harvard Medical School, and his colleagues at Boston Children’s Hospital (the group responsible for HealthMap.org), are working to make these data more available. They are tracking resistant bacteria through an online map called ResistanceOpen. The goal is to shed light on how much resistant bacteria is in your area and which antibiotics those bacteria are resistant to. (Full disclosure: I did my post-doc with HealthMap, leaving in 2013.)

Other groups track drug-resistant bacteria — like ResistanceMap put out by the Center for Disease Dynamics, Economics and Policy, based in Washington, D.C. — but it’s never been done at such a local level. ResistanceOpen provides data and information on four of the most dangerous types of resistant bacteria, including MRSA, the infection that Fells caught in his foot.

A screenshot from ResistanceOpen (Courtesy)

A screenshot from ResistanceOpen (Courtesy)

It’s not yet so detailed where you can get data on your local hospital, but currently you can search for information on which drug-resistant bugs are circulating in a 25-mile radius from your location, or any other location you choose. The hope is that if people know which resistant germs are in their area, it’ll help draw attention to the issue. One day, ResistanceOpen hopes to map data at the hospital level.

“I feel like antimicrobial resistance should be treated with the same urgency that other communicable diseases are met with and I believe it has to start with transparency and awareness,” Dr. Derek MacFadden, a Canadian infectious disease doctor who worked on the project, told HealthMap’s Disease Daily. “ResistanceOpen provides the public with both.”

While some of the data for the map comes from news reports about resistant bacteria, Dr. MacFadden, who is also a doctoral student at Harvard T.H. Chan School of Public Health, found much of the data for ResistanceOpen by scouring hospitals’ websites.

Hospitals routinely track antibiotic resistance on their wards and in their clinics. With that data they usually create a yearly “antibiogram” — a catalogue of bacteria found in patients treated at that hospital in the past year. Antibiograms help guide physicians at that hospital on how to treat patients by avoiding antibiotics that are unlikely to work. But antibiograms are not always public, so only the physicians (and patients) at that hospital benefit from the information. Continue reading

Quincy Medical Center Closing At Year’s End

After years of struggling to balance the books, Quincy Medical Center will close at the end of the year.

Steward Health Care says it is losing nearly $20 million a year at the hospital. It just doesn’t have enough patients — on any given night there are about 40, leaving 80 percent of the beds empty.

The latest setback for Quincy began in 2011, when the large Harvard Vanguard center in Quincy cemented relations with Beth Israel Deaconess Medical Center and began referring most patients to BIDMC Milton or the main BIDMC campus in Boston

Most of the patients who still come to Quincy use the emergency room, are treated and go home without being admitted. Steward plans to open a stand-alone emergency facility and an urgent care clinic sometime next year to handle these patients.

The hospital employs 680 workers. Steward has jobs open for 80 percent of them, says Steward Hospital Group president Mark Girard, with many of those jobs in Quincy. Continue reading

‘Good Death’ Still Eludes U.S. Health System Despite Decades Of Debate

reclaimedhome/flickr

reclaimedhome/flickr

By Richard Knox

Death is back in the news again. And it should be.

Death comes to us all. And in the U.S. at least, it’s increasingly likely to be inhumane, institutional and full of misery. That’s according to a growing body of evidence, including:

•A report last month from The National Institute of Medicine called “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.” It’s a 500-page indictment of U.S. end-of-life care.

•A new book by Boston writer-surgeon Atul Gawande on the subject called “Being Mortal: Medicine and What Matters in the End.”

•And recently, a must-read New York Times article — a powerful case study of how the American way of death has gone badly awry.

From these and other sources, one thing is clear: Too many Americans are still dying in hospitals and nursing homes; getting aggressive but futile care; and suffering more from the complications of treatment than from the pain of dying.

And with about 10,000 Baby Boomers turning 65 every day, it’s way past time to do something about it. “What is it going to take to ensure that patients in this country are receiving the right care at the right time in the right location, consistent with the right to choose?” Dr. Joan Teno wonders. “These are the things that keep me up at night.”

Teno, a Brown University faculty member, is among 21 authors of the recently issued Institute of Medicine report on dying in America. Continue reading

AG Deal With Partners Filed In Court: Restricts Growth, Costs

Massachusetts Attorney General Martha Coakley on Tuesday reached an agreement with Partners HealthCare that she says will alter the hospital network’s negotiating power for years to come.

The deal would resolve an antitrust investigation by the attorney general’s office and ultimately allow Partners to acquire South Shore Hospital.

“Our office was the first to shine a light on the ability of Partners to charge higher prices based on its negotiating power,” Coakley said in a statement. “Today’s resolution is the first action of its kind to directly address that market dysfunction.”

But many in the health care industry say they’re frustrated and angry about the process.

The Rev. Burns Stanfield, president of the Greater Boston Interfaith Organization, says the group is disappointed the agreement bypassed the state’s Health Policy Commission

“A proper review would need to have the agreement available before it is submitted to the judge, and for the Health Policy Commission to be invited to weigh in,” he said.

Continue reading

No Court Filing Yet In Partners Deal To Expand

WBUR’s Martha Bebinger reports that a negotiated agreement that would have let Partners HealthCare expand to include South Shore and three other hospitals is on hold.

Partners and Attorney General Martha Coakley had planned to file a deal in court Monday that the AG said would curb Partners’ market clout.

But a spokesman for the AG says “both sides are continuing to negotiate based on the agreement in principle announced last month.”

Massachusetts Attorney General Martha Coakley (Steven Senne/AP/File)

Massachusetts Attorney General Martha Coakley (Steven Senne/AP/File)

The deal would have capped Partners expansion through 2020 after the network, which is already the largest in Massachusetts, was allowed to add the four hospitals and 550 more physicians. Partners had agreed to limit reimbursement increases to the cost of inflation, also through 2020.

But the agreement was criticized by competing hospitals who said it would lead to higher costs. Insurers, consumer groups and employers have asked to review the details before a deal is final. The AG’s office says it expects to allow public comment, although it’s not clear how.

The parties have not set a new date for a filing a final agreement.

Partners Showdown: Hospital Coalition Wants More Scrutiny Of AG Deal

A group of Massachusetts health care providers is asking Attorney General Martha Coakley (who also happens to be running for governor) to make public details of a deal which will allow Partners HealthCare to acquire three hospitals.

WBUR’s Dan Guzman spoke with Tufts Medical Center CEO Michael Wagner, who says the deal would have a big impact on the state’s health care marketplace. “The concern is that Partners is a system that has currently three times of the size of any system in Massachusetts,” he said. “With the proposed AG deal, this would take it to four times the size of the next largest system.”

The coalition also includes executives from Beth-Israel Deaconess Medical Center and Lahey Health. The deal, which would allow Partners to acquire three hospitals — South Shore, Melrose-Wakefield and Lawrence Memorial — in exchange for implementing certain cost-cutting measures, could go to a judge for approval as early as next week.

partners

Guzman also talked to Richard Copp, a spokesman for Partners, who said that for more than two years, there has been a process which has been transparent in the media and followed state regulations for this deal. Copp added that Partners believes the deal will result in more coordinated care and rein in cost growth for health care and that the health care system has followed the state process — there have been hearings and meetings, and Partners has followed the law.

Here’s the full press release from the coalition:

Healthcare providers across Massachusetts including Atrius Health, Beth Israel Deaconess Medical Center, Cambridge Health Alliance, Lahey Health Systems, Tufts Medical Center and other hospitals and physician groups have formed a coalition calling for a public process around the recently proposed settlement between Partners HealthCare and the Attorney General.

“Although we are competitors, we have joined together to draw attention to the threats posed to the Massachusetts healthcare system by the proposed deal between the Attorney General and Partners HealthCare,” said Howard Grant, JD, MD, president and chief executive officer of Lahey Health. “Members of the public, as well as healthcare providers, have received little information about this deal, though it will permanently transform how we deliver and receive healthcare. The proposal was crafted without the input of, or review by, the patients, doctors, nurses, caregivers, policymakers, employers, and other stakeholders who have worked so hard to reform the healthcare system.”

Coalition members yesterday delivered a letter to Attorney General Martha Coakley outlining concerns about the “significant and deleterious impacts” the proposed deal would have on the “entire Massachusetts marketplace” and raising questions about why the settlement proposal bypassed the Health Policy Commission’s Market Impact and Cost Review process. Continue reading

Report: Fewer Infections Overall At Mass. Hospitals (But Problems Remain)

(UCI Irvine/flickr)

(UCI Irvine/flickr)

For the most part, patients are contracting fewer infections inside Massachusetts hospitals — but some problem spots remain, according to numbers from the state’s Department of Public Health.

WBUR’s Martha Bebinger reports:

It’s almost impossible to compare the quality of specific hospital procedures, but you can make a few hospital system comparisons.

For instance, the latest data show lower rates for three types of hospital infections — central line and surgical site infections for hysterectomies and colon operations. On the other hand, rates for urinary tract infections from catheters have increased.

Still, required reporting is spurring change, says Patricia Noga, VP for Clinical Affairs of the Massachusetts Hospital Association.

“When there is reporting and particularly when there is public reporting, people stand up and take notice of it,” Noga says. “Sometimes more than they would otherwise.”

Here are some specifics from the state Center for Health Information and Analysis:

•Central line-associated blood stream infections in Massachusetts have declined by 47%. In Massachusetts’ Intensive Care Units and neonatal ICUs, [such infections] declined by 57% and 49%, respectively.

•Surgical site infections related to abdominal hysterectomy declined by 23% in Massachusetts hospitals. While 8% of reporting hospitals had an observed to expected ratio greater (worse) than the national ratio, overall Massachusetts’ improvement is on track with positive national trends.

•Surgical site infections related to colon surgery declined by 19%. Massachusetts’ ratio of observed to expected infections is in line with the nation’s.

•Catheter-associated urinary tract infections have increased by 45% in the Commonwealth. In Massachusetts ICUs, [these types of infections] have increased by 64%. Among reporting hospitals, 15% had an observed to expected ratio greater (worse) than the nation’s. Massachusetts significantly lags national performance on this measure.

Continue reading

Restraining Partners? Rampant Speculation On A Deal In The Works

What’s up with that Partners-South Shore deal?

This question has come up in every conversation about hospitals in Massachusetts for the past three to four months, at least.  It’s important because the final resolution will be a benchmark for future hospital mergers, acquisitions and partnerships in Massachusetts and beyond. And it may finally address complaints that Partners Healthcare hospitals and doctors are paid more, in some cases much more, than most of their competitors.

If you’ve (understandably) lost track, here’s a recap:

partnersPartners announced plans to acquire South Shore Hospitals in June 2012.

The state’s Health Policy Commission concluded the deal would increase costs $23-$26 million a year.

Partners countered, saying that adding South Shore to its network, currently the largest in the state, would save $27 million a year.

The commission stuck to its original findings and sent a report to Attorney General Martha Coakley.  She, along with the U.S. Department of Justice, have been looking at whether Partners exploits its size and market clout to drive up health care prices and all of our premiums.

There are lots of theories about why we haven’t heard anything since Coakley acknowledged in March that she was in talks with Partners and South Shore.  Is there an impasse?  Are federal regulators clogging up the works?  What kind of pressure is Coakley (who is also running for governor) facing? I’ve heard all kinds of theories. Feel free to add yours below.

Coakley told the South Shore Chamber of Commerce last week that she expects to complete her review of the deal in a month or two.

Working with the Department of Justice, Coakley could sue to try and block Partners from bringing South Shore into its system.

But a deal that would limit Partners clout seems more likely. So what should it include?

Here’s where my random conversations with doctors, hospital executives and patients gets really interesting. The virtual water cooler chatter includes these possible scenarios:

1. Partners can add South Shore — and that’s it.  No further expansion for, say, five years or so (the time frame varies from three to 10 years). Keep in mind, Partners has already announced plans to acquire two North Shore hospitals after the South Shore deal is done.

2. Partners can add South Shore, but it must sell off another hospital of equivalent size or scope. Continue reading