practicing medicine


My Mother’s Surgery And One Doctor’s Substance Abuse

By Karen Shiffman
Guest contributor

USA Today reports more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction. This wasn’t news to my family.

Some 20 years ago, my mother was mauled by a dog. She was on vacation in Florida and went over to a friend’s house for dinner. To understand what happened next, you need to know a few crucial facts about her: She is afraid of dogs and barely five feet tall. When her friend opened the front door, her daughter’s dog — an Akita- tore out of the house and lunged . My mother turned away quickly. The dog lunged again. Because of her short stature, his teeth sunk into her calf. He all but ripped it off.

(Alex E. Proimos/flickr)

(Alex E. Proimos/flickr)

Blood everywhere. Screams. Tears. Ambulance. Thirty-nine stitches at the ER. She would need a skin graft.

And then there was the drama with the friend. Turns out, this wasn’t the first time the dog had bitten someone. Still, the family didn’t want the dog put down. Eventually, he was. My mother and her friend of 30 years never spoke again.

Back home in Boston, my mother was referred to a plastic surgeon at what is now Beth Israel Deaconess Medical Center. He was kind and I agreed with my mother that he should do the surgery.

The operation went well. I went with her to the post-surgery checkup. We both thanked the surgeon for doing such a great job and for taking such good care of my mother.

So, imagine my shock, in 2008, to read in The Boston Globe that my mother’s surgeon was fired for being impaired in the OR. And that he had been struggling with substance abuse for the past six years. Continue reading

Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy “flawed and irresponsible.” Here’s Alford’s response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Dr. Dan Alford

Dr. Dan Alford

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program’s stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients. Continue reading

Circumcision Boost: Study Cites Benefits, Notes Foreskin-Related Health Problems

New findings may offer a boost to proponents of newborn male circumcision: Researchers in the U.S. and Australia report that the health benefits of undergoing the procedure “exceed the risks by over 100 to 1,” and note that “over their lifetime, half of uncircumcised males will contract an adverse medical condition caused by their foreskin.”

The review, published online in the Mayo Clinic Proceedings, bolsters the position of mainstream physician groups, such as the American Academy of Pediatrics, which supports insurance coverage of the practice and full access for families who choose circumcision for their infants. But the new report is unlikely to silence critics of the practice, who have called it “insane” and a “disservice to American parents and children.”

Here’s some context, from the study, which shows a slight increase in circumcision among older men, but a decline among newborns:

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

“The latest data on male circumcision in the United States show a 2.5% overall increase in prevalence in males aged 14 to 59 years between 2000 and 2010. In contrast, there has been a downward trend in neonatal circumcisions, with the present analyses finding that the true extent of this decline is 6 percentage points.”

And here’s more from the news release:

Whereas circumcision rates have risen in white men to 91%, in black men to 76%, and in Hispanic men to 44%, the study authors found an alarming decrease in infants. To get the true figures they had to correct hospital discharge data for underreporting. This showed that circumcision had declined from a high of 83% in the 1960s to 77% today.

There seemed to be two major reasons for the fall.

One is a result of demographic changes, with the rise in the Hispanic population. Hispanic families tend to be less familiar with the custom, making them less likely to circumcise their baby boys.

The other is the current absence of Medicaid coverage for the poor in 18 US states. In those states circumcision is 24% lower. Continue reading

Flipping Health Care: From ‘What’s The Matter’ To ‘What Matters To You?’

Patient-centered care is all the rage, but what does that actually mean in the medical trenches?

It means “flipping” the entire notion of health care around, says Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement (IHI), speaking today at the nonprofit group’s annual national forum in Orlando, Fl.

Instead of traditional medical care, which focuses on a patient’s disease or illness by asking the question “What’s the matter?” Bisognano says providers should focus on the person and his or hers individual needs and lead with the much more intimate: “What Matters To You?”

An example: A standard mode of assessing whether a patient’s diabetes is under control is through traditional numeric measures, like blood pressure, cholesterol levels and blood sugar. But isn’t it more meaningful, Bisognano suggests, to measure in more human terms, like how many leg amputations and heart attacks were avoided by controlling diabetes, or how many fewer trips to the ER were needed? And of course, what was the dollar savings?

It’s worth listening to Bisognano’s far-reaching talk here, which touches on what health means to a 96-year-old (living pain-free and being productive) and highlights “centering pregnancy” — group prenatal and maternity care visits in which women and teams of providers support each other.

Bisognano also features a young Millennial named Trevor, a self-described “diabetes evangelist” who explains why he’s glad he has Type 1 diabetes (it’s so much easier to be healthy when you’re forced to focus on the nutritional content of food); and what true health means to him (answer: it’s all about staying high-energy in the erratic world of college student life).

Delicate Doctoring Moments: A Medical Error By Another Physician

(Alex E. Proimos/flickr)

(Alex E. Proimos/flickr)

What if you’re a doctor, and you discover one of your patients is the victim of another doctor’s mistake, say, a serious misdiagnosis or administration of the wrong drug?

What do you do?

It’s a delicate type of problem that’s rarely discussed, even while the whole question of how to better handle medical errors is gaining new attention and focus in hospitals and medical centers around the nation. (Many institutions are embracing a new “full disclosure” philosophy with more open communication, honesty and maybe even an apology when a medical error occurs, but these policies often take years to truly take hold.)

Dr. Jo Shapiro, chief of the Division of Otolaryngology and director of the Center for Professionalism and Peer Support at Brigham and Women’s Hospital, co-wrote an article in this week’s New England Journal of Medicine exploring the topic of how clinicians should talk to patients about a medical error caused by a colleague. In the piece, she touches on the institutional, cultural and emotional barriers to such open communication, and the challenges when one doctor feels, “This is not MY error.”

It’s important to think about this problem now, Dr. Shapiro writes, because medical care these days is often delivered by a team of clinicians across “multiple care settings.” She writes that much of the medical literature assumes that “the physician providing the disclosure also committed the error,” but that may not necessarily be the case. Here’s the hypothetical example at the top of Dr. Shapiro’s piece:

You are a young neurologist practicing in a small hospital. You admit a 55-year-old woman with hypertension and type 2 diabetes mellitus who had an embolic stroke at home. On reviewing the patient’s medical record, you notice that she appears to have been in atrial fibrillation during two electrocardiographic (ECG) tests during visits to the office of her primary care physician (PCP) for palpitations. Her PCP, an internist who provides many of your referrals, read both ECGs as normal and attributed her palpitations to “probable mitral-valve prolapse and anxiety.” The patient is currently in normal sinus rhythm. You show the internist the ECGs and express concern that they
indicate atrial fibrillation. He politely disagrees and says you are confused by noise from his old ECG machine. However, when you ask two cardiologists to look at the ECGs, both immediately say “A-fib.” The internist requests that you transfer the patient to his service.

I asked Dr. Shapiro a few questions — about the particular case she describes and the issue in general. Here, lightly edited and via email, are her responses.

In the hypothetical case of the neurologist in your piece, how does he or she speak up about the error, and also overcome the deep instinct to protect a colleague?

There is of course a strong pull toward loyalty that can lead one to not speak up.  We all have the sense that we are human and can make errors and we want to be treated respectfully by our colleagues.  But currently we understand that this loyalty should not stand in the way of transparency and compassion towards our patients.

So, should the first step be for the doctor who learns about the error to confront the mistake-making doctor? And if you do this, might you alienate this doctor forever?

Yes. Ideally one would contact the physician who had been previously caring for the patient so you could discuss your perspective and concerns with him/her.  Often, that physician might have a perfectly reasonable explanation regarding the care.  If not, it is still important to have the conversation so that two things can happen:  the MD learns from the error and the MD has the opportunity to discuss this with the patient and to apologize.

Have you experienced this personally?

Yes.  I have been a practicing surgeon for more than 25 years and on rare occasion, I have seen a patient where I felt the prior care had not been optimal.

Why might this situation (one doctor learning of another’s mistake) arise more in the current health care climate?

I think this issue arises more now only from an awareness point of view.  That is, the phenomenon of seeing that another clinician may have inadvertently made an error is not a new phenomenon.  What has changed is the understanding that patients have a right to know what has happened to them, and we as a medical community need to discuss and give feedback to our colleagues so that we can all learn from any mistakes and prevent them from happening in the future.

There’s a good deal of talk about more disclosure, honesty and apologies when it comes to medical errors, but are things truly changing? And which institutions are doing the best job ?

Yes, the culture is changing. Continue reading

Why I Left Medicine: A Burnt-Out Doctor’s Decision To Quit

By Diane Shannon
Guest Contributor

When I introduce myself as a physician who left clinical practice, non-physicians ask me why I left. They’re generally intrigued that someone who sacrificed many years and many dollars for medical training would then change her mind. But physicians, almost universally, never ask me why I left. Instead, they ask me how. They call and email me with logistical questions, wanting to learn the secret of how I managed the transition out of clinical medicine (read “escape”).

Earlier this month I attended a conference on physician well-being at the Massachusetts Medical Society where I heard an alarming statistic: the suicide rate among women physicians is more than two times that of women in the general population.

Diane Shannon, plagued by constant worry about patients, and fear of medical errors, gave up her career as a physician. (Courtesy)

Dr. Diane Shannon — plagued by constant worry about her patients and fear of medical errors — walked away from a career as a physician. (Courtesy)

It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health. As an internist, working in adult outpatient clinics around Boston, I had trouble leaving my work at work. I’d go for a run and spend the entire 30 minutes wondering if I’d ordered the right diagnostic test. I suffered from chronic early morning wakening, even on my weekends off. I startled easily. I found it impossible to relax. I worried constantly that I’d make a mistake, like ordering the wrong dosage of a medication, or that a system flaw, like an abnormal lab report getting overlooked, would harm a patient. I no longer remembered the joy I’d felt when I first began medical school, and I couldn’t imagine surviving life as a doctor.

I no longer believe it was weakness or selfishness that led me to abandon clinical practice. I believe it was self-preservation. I knew I didn’t have the stamina and single-mindedness to try to provide high-quality, compassionate care within the existing environment. Perhaps, due to temperament or timing, I was less immune than others to the stresses of practicing medicine in a health care system that often seemed blind to humanness, both mine and my patients’.

That’s not to say that I don’t miss practicing medicine. I do. I miss engaging in meaningful interactions and being of service, reassuring an elderly woman that we could make her emphysema easier to endure, bearing witness to a cancer patient’s grace in the face of death, supporting a college student facing an unexpected pregnancy. I miss spending my days in deeply meaningful work. Continue reading

Has Prescribing Psychotropic Drugs To Kids Peaked?

Are doctors starting to ease off on prescribing psychotropic drugs to young kids?

This seems to be the conclusion of a new study published in the journal of Pediatrics this week. The study’s design was relatively simple: gather data on 2-to 5-year-olds from national health surveys, and see what trends emerge. The findings? While behavioral diagnoses in young children have increased over the past two decades, prescriptions for psychotropic medications have been cut in half.

(Southworth Sailor/flickr)

(Southworth Sailor/flickr)

Why was there a prescription peak that has now stabilized, and what could explain the drop? I contacted Dr. Tanya Froehlich, a contributing author of the study and associate professor at the University of Cincinnati Department of Pediatrics, to shed some light on this phenomenon. She responded via email.

Dr. Froehlich attributed the decline to two major factors: regulatory controls and increasingly cautious doctors. Specifically, she said, decreasing prescription rates “may be due to physician and public concern about these medications spurred by a number of FDA advisories issued in the mid- to late 2000’s, including the black box warnings on selective serotonin reuptake inhibitors (SSRI) and atomoxetine, and other advisories regarding psychostimulant-associated side effects.” Continue reading

How Many Patients Does One Nurse Treat: Ballot Question On Staffing

“Just Ask!” That’s the slogan for a new campaign by the Massachusetts Nurses Association (MNA). The union is encouraging people to ask how many other patients their nurses will be treating that day. The slogan is meant to draw awareness to what the nurses union sees as a growing disconnect between the profit-driven healthcare industry and the quality care of its patients.

Alex E. Proimos/flickr

Alex E. Proimos/flickr

The campaign’s goal is to enact minimum mandatory staffing levels, capping the number of patients per nurse. After a similar measure failed to pass the state legislature in 2008, the MNA wants to take the issue directly to voters through a ballot initiative. The union has submitted the text of the Patient Safety Act to the Attorney General’s Office; the act’s terms include limiting nurses to having up to four patients in surgical units and in emergency rooms. Once approved, the union will need to collect 70,000 signatures by November for the Patient Safety Act to appear on the 2014 ballot.

Currently, California is the only state that has mandated nurse-patient ratios. However, this topic may well seem familiar to Mass. voters: state nurses have sought staffing legislation since 1995, and 2011 saw fraught contract negotiations between Tufts Medical Center and its nurses. CommonHealth analyzed how Tufts’ lower nurse ratio affected patient care.

Lynn Nicholas, president of the Massachusetts Hospital Association, alluded to the idea’s long history by calling the current initiative petition a “repeat of an arcane idea that has no merit” in a statement. Continue reading

‘Compassionate Care’ In U.K. After Deplorable Care, Alzheimer’s Drowning

Sometimes it takes a disaster to make things better.

For Ken Schwartz, it was a diagnosis of late-stage lung cancer at age 40 that prompted this realization: at the core of first-class health care is the compassionate, human bond between patient and provider.

Schwartz’ terrible medical ordeal — he died in 1995, ten months after his diagnosis — gave rise to the Schwartz Center for Compassionate Healthcare, and the nonprofit’s signature program, the “Schwartz Center Rounds,” which helps medical professionals better manage the tough social and emotional issues they face as caregivers. (We wrote about one particularly fraught case involving a speedy organ donation here.)

These days, Schwartz Rounds are held in about 300 hospitals and health care institutions in the U.S. and there’s currently a waiting list of sites hoping to launch the program.

Now, in Britain, the National Health Service is adopting Schwartz Rounds in dozens, and eventually hundreds, of hospitals. Why? According to a news release from the Schwartz Center, U.K. Health Minister Dr. Dan Poulter says the program is criticallly needed: “Shocking failures of care [in our National Health Service] demonstrate the need for more compassionate care right across hospitals and care homes. Schwartz Center Rounds have been shown to help hospital and care staff support each other and learn about how to deal better with tough situations, and spend more time focused on caring for patients in a compassionate way.”

According to media reports, a number of horrific health-related disasters occurred at NHS hospitals over the last couple of years. One particularly alarming case involved the drowning of an Alzheimer’s patient who was supposed to be closely monitored by care providers. Continue reading

Paying Tribute To A Doctor’s Invaluable Teacher: A Dead Body

For many doctors, the most important person on their journey from pre-med to licensed healer is dead.

“When you start medical school, you begin to learn the details of cells and tissues and development and disease,” said Jared Wortzman, president of the Tufts University School of Medicine class of 2016. “But if you ask anyone here they’ll tell you, you don’t really become a medical student until the moment you meet your cadaver.”

Edmund Chilcoate in his Coast Guard days (Courtesy)

Edmund Chilcoate in his Coast Guard days (Courtesy)

Wortzman spoke at an unusual gathering last week — a memorial service for the men and women who donated their bodies to the anatomy lab at Tufts and a reception for their families.

One of the donors was 83-year-old Edmund Chilcoate.

“This is when he was a baby. He was cute, wasn’t he cute?” said Kim Begin, one of Chilcoate’s two daughters. Begin flips the plastic-covered pages of a brown leather photo album while three of the first-year medical students who probed and dissected Chilcoate’s body lean in to look.

Continue reading