Home / Tag Archives: News Commentary (page 5)

Tag Archives: News Commentary

Dr. Nurse

I really don’t like it when people call me “doctor.” The only time that I ever refer to myself as “Dr. WhiteCoat” is when I first enter a room and introduce myself to a patient. That way they know that I’m not some schmuck off of the street who wandered into the wrong room. Patients came to the emergency department to be evaluated by a doctor and, like it or not, I’m that guy. However, almost all of the staff that I work with call me “Whitey” and many patients call me by that nickname. The rest call me “Dr. Whitey” apparently because they feel uncomfortable addressing me without the “Doctor” moniker. Personally, it annoys me to no end when people correct others and demand to be called “Doctor”. I met a child’s parent at a football game and introduced myself. “Hi, Mr. Smith, I’m Thaddeus WhiteCoat. Nice to meet you.” “It’s Doctor Smith. Dr. Mark Smith.” “Oh. My apologies. What’s you’re specialty?” “I have a PhD in psychology.” “Oh. Nice.” In the back of my mind I was thinking about saying something like “Unfortunately, we’re in football stands so I can’t genuflect in front of you. Please forgive me.” Enough rambling. In the NY Times a couple of weeks ago, there was an article about nurses who want to be called “doctor.” Actually, the nurses in the article earned the title. They have doctorates in nursing or other PhD degrees. Is it good public policy to allow a non-physician to use the title “doctor” in a medical setting without having a medical degree? Personally, I don’t care what people want to call themselves. If your ego is that fragile, call yourself Grand Exalted Supreme Poobah Doctor Nightingale for all I care. Introduce yourself that way at dinner parties. Command people to address you that way. Knock yourself out. When someone introduces themselves as “doctor” in a medical setting, it evokes a specific and consistent response from just about any patient: The person in front of me is a physician. Whether the patient thinks the “doctor” is intelligent or a quack depends upon multiple other issues, but the presumption is that “doctors” have gone through a lot of medical training and are capable of independently evaluating, diagnosing, and treating the medical condition for which the patient is seeking care. In my view, calling oneself “doctor” when one is not a physician is misleading. Think about it. What if you bought a “hybrid” car, then opened up the hood to find a regular engine with a “hybrid” soybean growing in a crevice. Hey, it is a hybrid, isn’t it ? Or what if you bought a “Big Mac” and unwrapped a sandwich with two buns and a piece of cheese that was made by some guy named “Big Mac”? States tend to frown upon nurses and physicians assistants referring to themselves as “doctor” as well. Many state Medical Practice  Acts, Nursing Practice Acts, and Physician Assistant Practice Acts prohibit non-physicians from leading a patient to believe that they are capable of independently providing medical care. There have also been lawsuits against physician assistants who have not disclosed their credentials. Maybe the increasing number of non-physicians who refer to themselves as “doctor” will create a “caveat emptor” environment where consumers will inquire about the credentials of a health care provider before seeking care. I see that as a good thing. Maybe hospitals will use the idea to enhance their advertising: “This hospital emergency department is staffed exclusively by board certified emergency department physicians.” We haven’t reached that tipping point, yet, though. Given ...

Read More »

Time To Join The Debate Team?

I’m getting to dread Friday evenings in the emergency department. This past Friday, I saw six patients who had assorted injuries from football games. Six. Two of them had concussions, which goes along with a recent study published by the CDC showing that concussions are on the rise. See articles here, here, and here. CDC report is here. There is a lot of debate on how to manage sports-related concussions. The American Academy of Neurology essentially recommends discontinuing participation in the sport until symptoms resolve and appropriate evaluation … by a neurologist (or other physician with “proper training”) … prior to being cleared for participation. The Consensus statement on concussion in sport (2008) recommends physical and cognitive rest until symptoms resolve and then a graded return to activity prior to medical clearance. There is also an excellent but dated (1999) article in American Family Physician containing a summary of the then-current treatment recommendations for concussion. Several recommendations included discontinuing participation in the sport if several concussions occurred. Anyone symptomatic when I see them gets taken out of sports and gym until cleared by their physician. I also had another “oops” from Dragon Naturally Speaking related to the football injuries which was almost finalized in the medical record … I dictated “… followed by hitting head on another player’s football helmet.” Dragon spat out ” … swallowed getting hand in another player’s foot vomit.” Haven’t seen foot vomit in a while, but I know I wouldn’t want to be getting my hand in it.

Read More »

Pennsylvania Medicaid's Cost "Savings"

While scanning the news this morning, I laughed out loud at Pennsylvania’s newest proposal to cut Medicaid costs. According to this Kaiser Health News report, Pennsylvania plans to pay Medicaid recipients up to $200 to visit “higher quality and lower cost hospitals and doctors.” Gary D. Alexander, the Pennsylvania secretary of public welfare, compared the idea to a shared cost savings. “If the state saves $1,000 on a medical procedure we may give the beneficiary $100 or $200 as a reward.” Does anyone see a problem with this approach? Let me lay it out for Mr. Alexander, just in case someone who reads my column has his e-mail address. In some of the inner-city emergency departments where I have worked, there used to be a policy that patients would be given subway tokens … or bus fare … or cab vouchers at the conclusion of their ED visit. The theory was that hospitals didn’t want patients loitering in the emergency department waiting rooms after their visits trying to find a ride home.  The policy was also viewed as creating good public opinion since the hospitals were making sure that patients had a way home if they came by ambulance and had no other means of transport. Ambulance transport to the hospital is provided at no cost to the patients. Ambulance transport home must be paid with credit card. Once the general public got wind of the cab voucher policy, guess what happened. Patient volumes increased. Ambulance transports increased. Wait times went up. People waited hours for free medical care so that they could then get their free subway token … or bus fare … or cab vouchers at the end of their visit. The policies were quickly discontinued. If Pennsylvania begins paying people to go to “better” hospitals, the cab voucher fiasco will occur in Pennsylvania, only on a much grander scale. Once Pennsylvania Medicaid recipients learn that they will be paid to go to a certain hospital for medical care, those hospitals will be deluged with patients. To those receiving public medical assistance, the medical care is free, the medical testing is free, and the medical procedures are free. Now, with a monetary incentive to have a procedure done at a given facility, what do you expect will happen? Patients get $200 if they get a cardiac catheterization at one hospital versus another? Twelve year olds will go to those emergency departments complaining of crushing chest pain. Patients get $50 if they go to one emergency department that provides “higher quality”? There will be lines out the door. Medicaid will end up footing the bill for an increase in medical care because it has incentivized the patient population to seek out that care. Brilliant. Just brilliant. Mr. Alexander even went to a meeting of “300 health insurance executives” in Washington and pitched his plan. I’m sure he got a little round of golf claps for his innovative approach to reducing health care costs. This is what happens when people who make policies have no practical experience in the industry in which they are making the policies. Mr. Alexander was a political science major in college and has a law degree. You want to decrease utilization? Pay Medicaid patients that same $200 at the end of a year only if their medical resource utilization (ED visits/prescriptions/whatever other variable you want to control) is below the average utilization for other Medicaid recipients for that year. Kids get $50 per year. Send out letters to those who didn’t get the money telling them why they didn’t get their “incentive payment”. That policy ...

Read More »

Walgreens Blows It

Scanning the news this morning and found a story that really bothered me. Walgreens fired one of its Benton Harbor, Michigan pharmacists. No big news there. However, the reason the pharmacist was fired was more of a story. Walgreens fired the pharmacist for thwarting a robbery. Video posted on the mlive.com site shows two hooded thugs running into the store with guns. They took one or two employees hostage and, when they saw the pharmacist behind the counter, one jumped over the counter to presumably take the pharmacist hostage, too. The robber tried to shoot, but his gun jammed. That’s when pharmacist Jeremy Hoven whipped out his own handgun and shot back. The robbers ran away with their tails between their legs. Walgreens has now terminated Hoven’s employment because Hoven violated Walgreen’s “non-escalation” policy. Exactly how much more “escalated” can things get after someone tries to shoot you dead at your job? It’s not like Hoven detonated a bomb or anything. Walgreens management is dead wrong on this move. I understand the reasoning behind not wanting to encourage shootouts in the store, but the right of employees to take steps to avoid being found amongst a group of employees in a storage room with bullet holes in the head trumps that reasoning every time. It’s almost as if the policy is saying “come rob us, our employees won’t shoot back!” Multiple commenters to the article said that they will take their business elsewhere. If Walgreens doesn’t rectify this situation quickly, I’ll likely add my name to that list.

Read More »

More Florida Medical Follies

Yet another reason to stay away from Florida if you are a physician. The inspectors and health care agencies down there leave quite a bit to be desired. The Florida Agency for Healthcare Administration cited an emergency department’s staff for failing to give “adequate care” to 13 week pregnant patient before she had miscarriage of twins. The timeline of events for the patient was outlined in this article. At 9:45 a.m. the patient came to the emergency department with pelvic pain and vaginal bleeding. At 10:30 a.m., the patient was diagnosed with pain and bleeding, a urinalysis and a battery of blood tests ordered, but there was no test ordered that would have revealed her glucose level. There was also no discussion of whether to discontinue or maintain the patient’s insulin pump. Ultrasound tests were ordered, then changed, which “caused a delay.” At 11:45 a.m., the patient was bleeding heavily and was “in obvious labor” according to state inspectors. The ultrasound scan showed both fetuses had normal heart rates. The state inspectors stated that the emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.” At 12:25 p.m., the physician performed a pelvic exam and suctioned some large blood clots from the vaginal canal. The patient then “spontaneously aborted one of the fetuses.” Inspectors noted that the patient was not informed of any risks of performing a pelvic exam, nor did she give informed consent for the pelvic exam. A second ultrasound was ordered. By 2 p.m., the second ultrasound showed a normal heartbeat in the remaining fetus. At that point “the doctor took no steps to stop labor or maintain the second pregnancy.” Additionally, the emergency physician’s report showed that the second fetus had no heartbeat, which conflicted with the radiologist’s report. At 4 p.m., the patient’s blood-sugar level was measured and found to be “critically low.” She then received orange juice and IV dextrose. At 5:30 p.m., an obstetrician arrived and performed a pelvic exam. He ordered no additional procedures or medications. At 6:15 p.m., the woman passed the second fetus. The inspectors stated that the physician failed to monitor blood sugar levels, failed to respond to the patient’s bleeding and pain, and failed to intervene to stop her labor. In eight of ten other cases that inspectors reviewed, the hospital was cited for failing to document the amount of the patient’s blood loss, failing to record vital signs, and failing to record other case information. We need more information about the other cases, but even without extra information, I’m still calling out the inspector and the Florida Agency for Healthcare Administration. Many of these citations are uninformed and inappropriate. #1 No discussion documented about whether to continue or discontinue the patient’s insulin pump. Such discussions are rarely held in the emergency department. Should the patient’s blood glucose have been checked sooner? Probably. However, if a patient is not having symptoms suggestive of low blood glucose, how often should the glucose level be checked — especially with an unrelated complaint? Should hospitals be cited when glucose levels aren’t checked in a diabetic patient with an ankle sprain or laceration? #2 The emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.” How much bleeding was there? What were the patient’s vital signs? Notice how the report is vague about the findings? Also notice how the report doesn’t state what the emergency physician should have done, and only made vague accusations about what the emergency physician didn’t ...

Read More »

Hurricane Safety, Part Deux

Hurricane Irene is beginning its trek up the East Coast. The damage from the storm is predicted to be horrific. Any of you self-righteous attorneys from New Orleans want to post a comment prospectively telling all the hospitals everything that they need to do in order to avoid being sued for an “inadequate response” to this natural disaster? Any experts in disaster preparedness want to chime in? Anyone? Bueller? Bueller? [crickets] Yeah. Didn’t think so. Yet when some patient gets a fleck of dust in their eye from the 120 mile an hour winds after the storm has passed, based on the recent $25 million settlement from Katrina lawsuits, I’m betting that the attorneys will be falling over each other to file lawsuits to retrospectively tell everyone what the hospital did wrong in preventing said speck of dust to become airborne and lodge in the patient’s cornea, though. God forbid that a hospital’s backup generator breaks down. Just sign a check. While I’m at it … Any person living east of the Mississippi River is hereby put on notice that a hurricane is coming. You need to take adequate measures to protect yourself from any potential injury or death from the hurricane. This may include moving yourself out of any hospital within 300 miles of the hurricane and relocating yourself in a hospital west of the Mississippi River. Is that enough to prevent people from suing?

Read More »