Friday, October 24, 2008

Smoke and Mirrors

A NY Times article refers to a new study from the BMJ involving the prescribing of placebos to patients. Many ethical dilemmas are raised with this practice. The "placebos" referred to in this study weren't placebos at all, they were either vitamins or different classes of pain management medications. Wiki defines Placebo as:

... a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity. Any therapeutic effect is thought to be based on the power of suggestion.

The word placebo is Latin for I will please.

Prescribing placebos is only part of the game. There is also the ordering of expensive lab work and diagnostic tests that go hand in hand with the powers of suggestion. I try to be mindful of the tests that I order and explain the risks and benefits of such tests/treatments.

Sure, there have been times when I've contemplated creating my own "S-Pak" in the hopes of creating a magic treatment. But I've found that presenting basic health information, offering rationale and engaging in two-way communication goes a lot further and is much more meaningful than trying to dupe a patient.

Thursday, October 23, 2008

Are We Headed for a Nursing Crisis?

On October 24, NOW on PBS will explore a projected nursing shortage that could impact quality
of and access to care for millions of patients.

Be sure to tune in! Below is the press release:

Show will highlight Innovative solutions in New York City and elsewhere

NEW YORK, September 26 – A U.S. government study projects that by the year 2020, there will be a nationwide shortage of up to one million professional nurses . The nursing shortage is already placing strains on the entire medical system. On October 24, 2008, the Emmy Award-winning newsmagazine NOW on PBS will examine the root causes of this crisis, and innovative efforts to reverse the trend.

Even though qualified nurses are in high demand and hospitals are offering attractive incentives, many are leaving the profession. Even more alarming: few are choosing to teach the next generation of professionals. As a result, tens of thousands of applicants are being turned away from the nation's nursing schools.

The production is supported in part by a grant from the Barbara and Donald Jonas Family Fund (more information is available at:

Friday, October 17, 2008

Culture Shocked

A New Jersey jury recently awarded $400,000 to a deaf patient because her physician refused to provide a sign language interpreter throughout their visits. The patient ultimately switched physicians since the steroids she was receiving caused facial edema. The new rheumatologist subsequently took her off steroids and was able to explain that the edema was a side effect of the steroids and not from her illness.

This case presents many ethical dilemmas for the practicing clinician. I have seen other blog posts related to this case. The knee-jerk reaction talks about moral obligations and financial implications for the physician to hire an interpreter that would result in a net loss for the visits (the visits were reimbursed at $49 and the interpreter would cost about $150-200/hr).

Those angles miss the point. Where is the culturally competent care? Cultural Competence is defined as: (via wiki)

... an ability to interact effectively with people of different cultures. Cultural competence comprises four components: (a) Awareness of one's own cultural worldview, (b) Attitude towards cultural differences, (c) Knowledge of different cultural practices and worldviews, and (d) cross-cultural Skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures.

If providers can't communicate with their patients, what good is that?

The physician's malpractice didn't defend the claim and will not cover the liability because quality of care was not an issue. I say, it wasn't?!? What comprises "quality" if the patient doesn't understand what the treatment plan is? Shame on the insurance company. Do they interpret "quality" as only being able to write prescriptions appropriately and treating lab values?

Maybe I have a different idea of quality or competent care. My view involves communication in addition to the science of rendering care. What good is it to treat symptoms and lab values if you can't communicate about the disease process, side effects, complications, etc?

I don't think providers need to bear the ultimate financial brunt of providing culturally competent care. This is where we need real leadership from our elected officials. It is so easy to think of healthcare in terms of patients, nurse practitioners, physicians, insurance companies and medications. Each patient brings a uniqueness to their condition that is undeniable. We have for too long subscribed to the "one size fits all" approach. We need to shift our focus on individualized, evidenced-based care.

Finally, the patient also needs to participate in this process as well (the article states that she reportedly handed the physician a business card of a sign language interpreter). Was that enough? It amazes me there was no middle ground mentioned.

What could've been done differently to have avoided such a drastic outcome? Perhaps an interpreter could've been hired for a specified number of visits. Why couldn't the patient and physician split the cost of the interpreter? What state/federal programs are in place to help these providers & patients in these situations? Did the patient's own health insurance have any programs in place (a quick google search came up with a list of insurance company programs that assisted with these types of situations).

This case also carries American's with Disabilities Act (ADA) implications. It is largely because of the ADA laws why this money was awarded and the case was won. But what about the conditions that don't fall under this Act? Providers still need to find ways to deliver care that is individualized. Having cultural intelligence doesn't make the provider's job easier however, it does enrich one's practice so that patient's needs are appropriately met.

The great thing is if you can't find a provider that is willing to partner in your care, you have the choice to find one that will.

Monday, October 13, 2008

Drive Through Flu Shots

Here is an article about a drive through flu shot clinic in Pennsylvania. The service is targeted at Seniors and health officials devised a system regarding which lane you drive up to and other logistics regarding the vaccination.
At first, I thought it was another gimmick. However the more that I thought about it, it does make sense. I've had a few requests over the years to vaccinate seniors in the drive-by fashion. This always put me in a difficult situation -- not because of the actual injection -- but what happens if there is a reaction and how can I ensure that they wait the recommended 20 minutes post vaccination without driving off into the sunset?
From a public health perspective, it makes complete sense. High-risk patients should get the immunizations and we must examine new ways to make this happen. We certainly can't visit them all in their homes. As long as there is a well-thought out system with policies and procedures in place, ideas such as this will prompt us to deliver quality care in non-traditional ways.
And as a reminder, get your flu shot! Here is a link to the American Lung Association's Flu Clinic Locator. There is plenty of flu vaccine to go around this year.
(image courtesy of Flickr)