[QUOTE=Dori Schatell;19912]Mark, I think you’re throwing the baby out with the bathwater here. Don Berwick is a passionate advocate for patients’ rights, and doing what the patient wants and needs, not what the professionals think should be done. If you read his essay, you’ll see where he’s coming from. Healthcare benefits aside, he is a STELLAR candidate to run CMS. I doubt it would be possible to find a better one.
In case folks don’t read the whole essay, here is a highlight–Don Berwick’s suggestions for “rules” for hospitals to be sure they meet patients’ needs:
(1) Hospitals would have no restrictions on visiting—no restrictions of place or time or person, except restrictions chosen by and under the control of each indi- vidual patient.
(2) Patients would determine what food they eat and what clothes they wear in hospitals (to the extent that health status allows).
(3) Patients and family members would participate in rounds.
(4) Patients and families would participate in the design of health care processes and services.
(5) Medical records would belong to patients. Clinicians, rather than patients, would need to have permission to gain access to them.
(6) Shared decision-making technologies would be used universally.
(7) Operating room schedules would conform to ideal queuing theory designs aimed at minimizing waiting time, rather than to the convenience of clinicians.
(8) Patients physically capable of self-care would, in all situations, have the option to do it.
Imagine how different healthcare could look if his philosophy prevailed?[/QUOTE]
Dear Dori, I usually agree with all that you post, but I can’t see how these will improve care.
(1) Hospitals would have no restrictions on visiting—no restrictions of place or time or person, except restrictions chosen by and under the control of each indi- vidual patient.
Many inner city hospitals have security issues. In fact, even in rural areas, securing the new born areas is a primary issue with many kidnappings documented in the last few years. In addition, some times nurses actually bath patients so visitors would impose upon the schedule of work that simply has to have a time to be completed. In addition, I have seen sick patients overwhelmed by a room full of visitors. At times, peace and quiet is what patients need. Not having any limitations to visitors seems like chaos to me. Many patients in the ICU have liberal visitation rules for significant others. I have seen a spouse spend the night on a cot or even in chairs side by side the nursing staff. Most hospitals are flexible when it comes to the spouse in private rooms.
(2) Patients would determine what food they eat and what clothes they wear in hospitals (to the extent that health status allows).
Some patients are in the hospital because of dietary indiscretions such as CHF patients who can’t put down the potato chips and pickles. Sodium levels in food need to be controlled as part of the therapy in these patients. It can literally mean the difference between life and death in a poorly compensated CHF patient. In addition renal patients and diabetics rounded out those that truly have dietary needs. I just don’t see this as something that is not considered as part of the therapeutic arsenal of physicians. We would hope that most patients would make the right choices, but man do not.
(3) Patients and family members would participate in rounds.
I have spent many years learning how to listen to my patients which is the most effective tool in diagnosis and then curing illnesses. I am not sure what he would mean by this since patients and family do participate in rounds, but then there truly is a place where frank and technical talk must take place between the members of the medical team. In fact, the medical needs the privacy of closed doors to work out conflicting goals of therapy between specialists at times. Not that anything needs to be hidden, but instead, the peace of mind of the patient and family is a consideration that is actually part of the therapeutic approach. A patient and his family that is scared and stressed is a patient that will not do as well as a patient who is comfortable and at ease. There are times where the physiology of the illness dictates different goals between specialists such as increasing fluid for the kidney but decreasing fluid for the heart. There is no right or wrong way to approach that but a balance between the two that sometimes just doesn’t exist.
In addition, once you get beyond the training institutions, most doctors have such conflicting schedules that you could never have joint rounds with all the team members at one place and time for every patient in the hospital. The reality is that the team usually sees the patients sequentially throughout the day according to the dictates of their individual schedules. The only times we would have joint rounds were with family conferences discussing difficult decisions. In such a case, they were part of these rounds. They have started doing this in the renal units and it imposes a large burden on the staff and is not efficient time wise. Most the time the dietician and the social worker have to come back after rounds to get the information that they need. It is just an unworkable regulation in a hospital setting.
(4) Patients and families would participate in the design of health care processes and services.
Many hospitals already have multidisciplinary teams including patients and other “lay” people that often improve care dramatically.
(5) Medical records would belong to patients. Clinicians, rather than patients, would need to have permission to gain access to them.
How would something like that work? What if the patient and family decline, how will a doctor care for such a person.? In addition, who is going to secure the records? One aspect of the medical record is to document exactly what is happening in the minds of the medical team as they care for the patient. In such, the fact that these records belong to those that are assembling the record is for our own protection as well as for the communication of the treatment plan to the rest of those involved in the care of the patient. I have never had any difficulty having patients or family reading the medical record, but in a secure environment where the record remains intact.
I spent several years in the Army where patients were responsible for their own medical records. I had a false accusation made against me by a patient mad at me for refusing to give her controlled medications. She removed all of my documentation on how I referred her to headache specialists and pain specialists and the only way in which I did not get into great trouble since her father was a 3 star general was the fact that I kept a carbon copy of ALL of my notes. She removed about 12 pages out of the clinical record in an attempt to incriminate me. She was able to get an inquiry into her care through the congressional review that many people are aware of, but in this case with her father’s political clout got a Presidential inquiry. We had to do depositions and President Bill Clinton signed off on the completed evaluation. If it were not for my habit of carbon copying ALL of my clinic notes, it is possible I could have been unfairly placed under a court martial.
Simply put, I would NEVER treat any patient where they controlled the record keeping and I couldn’t. The legal system can be incredibly punitive to doctors and proper legal documentation to show we are adhering to the standard of medical care often is the only thing that keeps us out of trouble. If the patients want their own records, so be it, but I would by self preservation keep my own separate set of records in such a system. I am sure the lawyers will love this system if it is ever enacted since doctors do not have the same constitutional protections that the ordinary citizen has. If it is not documented in the chart, it is assumed it wasn’t done or thought of. Patients have bad outcomes due to diseases outside of the control of doctors. I had one of my colleagues that was successfully sued over smoking and the heart attack was blamed on the doctor because he never documented in his notes smoke cessation advice. This was despite the fact that other doctors before him had documented smoke cessation and the risks associated with smoking in the chart. He was an older physician that spent the time with the patients instead of the time with the chart. Score one for the lawyers.
(6) Shared decision-making technologies would be used universally.
I have seen cases where the proper algorhythm was used and the patient died because of not going with a doctors hunch. No case fits all predesigned outlines.
(7) Operating room schedules would conform to ideal queuing theory designs aimed at minimizing waiting time, rather than to the convenience of clinicians.
MOst patients do not understand that operating rooms use specially designed software to schedule multiple surgeries a day. Believe it or not, doctors cannot predict what they will encounter when they operate on patients and what should have taken a certain amount of time may take 2-3 times that time due to specific patient characteristics. My day as a physician on call was usually predicated on who was the most in need of urgent treatment and who was stable. The patients perception may have been that was at my convenience but in reality, a doctors schedule is hectic and filled with one emergency after another all day long. The sickest patients get the attention first. That was the dictates of my usual schedule. Isn’t there a built in bias against doctors in this statement? Most doctors spend the day running from patient to patient with little time even to eat.
(8) Patients physically capable of self-care would, in all situations, have the option to do it.
If a patient is capable of self care, invariably they should be discharged home if at all possible. For those in a hospital situation, there are procedures that need to be done correctly and this takes training and dedication to learn, for instance home dialysis which takes minimum of 3 weeks in most cases. I do agree that a person well versed in diabetes often knows their own body better than the nurses or doctors and some aspects of their care are best in their hands. It all depends on what part of the care we are discussing.
I frankly do not know how I would operate in such a system as described above. I am one physician that spent an inordinate amount of time with my patients and communicated openly with all of them. But there comes a point in time where I needed to sit down at my desk and do my work. Part of that work included the very important task of documenting our conversation, the risk, benefit and alternatives of any informed consent given and the treatments and diagnostic data. In fact, the majority of my record keeping was self protective documentation above and beyond what was needed to communicate to my colleagues. It is simply a fact of medicine that every encounter could end up under the scrutiny of a court. In such, those are MY records to prove I have acted in accordance to accepted medical standards. All medical records in my system were available under the proper procedure for the patients, but they clearly belonged to my HMO for our legal protection as well as for the communication of facts.
There are many ways in which we can enhance patients rights and access to medical records as well as involving them in the “team” concept, but there has to be a way for docs and nurses to just simply do their work once the discussions are completed. The outcome of such a system as outlined above would be several hours work each day to all the professionals day. Well that add to patient care? I vote a resounding no, it will not.
Case in point, my wife had to have an emergency surgery a few years ago. It was in the middle of my work week. I was able to cancel clinic for those two days but there were a few items that had to be done those two days. I spent almost the entire 48 hours she was in the hospital with her except for two hours each day. The first day, she was only 4 hours post op when I left. I came back about 2 hours later and no nurse had been in to see her. She couldn’t reach the table for some ice water because of the IVs and a urinary catheter. She dropped the call button for the nursing station. Yet the documentation was completed in her chart. The second day, the only time the nurses came into her room was for BP checks. I took her to the bathroom and helped her in and out of bed myself. The nurses of today are so busy documenting JCAHO requirements that they no longer have much time at all for actual patient care such as bed baths. The tasks that I helped my wife with were the tasks that 30 years ago were solely in the usual care of the nursing staff. In many ways, today you have to do self care because the nurses are too busy documenting the charts to keep the hospital out of trouble with JCAHO. I just don’t see this as ending in improved patient care which is what I believe he is trying to communicate.
I just read through the essay. The cardiac cath case is something I would like to comment on. I spent a fair amount of time in the ER taking care of heart attack patients. The cardiac cath room is a place that I used to go and observe all the time while I was writing up my report. It is a small space with a lot going on very rapidly under sterile conditions. The patient is completely draped and there is usually a circulating nurse and a scrub nurse standing beside the doctor. Things happen very fast and the techs often are moving radiology equipment and quickly gathering supplies. There just is not a lot of room for any extra people. As the treating physician, I was never allowed in the room itself. I have had fearful patients before the cath, and I served the medical team by holding hands and telling them straight to their face that they had every reason to trust the people that were going to be in the room with him.
Instead Dr. Berwick appears to have added to her fear. Sometimes it is better to give a comforting word that settles a patient. I think Dr. Berwick did not at all handle that case as I would even if it was my own wife. When she had her emergency surgery, I could have insisted on going into the operating room but that would have just been a distraction to them. Instead, I held my wife’s hand, prayed with her and reassured her that my colleagues were the best in the business with in a very real sense they were. Is Dr. Berwick implying that I should have insisted on going into the OR and becoming a distraction to my wife’s medical team? I believe he had the right title, he is an extremist view in this article.
