Body Part Medicine & Disconnected Care

I’m addressing what I’m calling “Body Part Medicine & Disconnected Care” in reaction to a national survey released by the Campaign for Better Care. The survey of over one thousand adults 50-plus years found that older people who are struggling with one or more chronic conditions also struggle with poor care coordination and inadequate communication among the doctors that treat them. It’s due in large part, as a result of specialized medicine.

It’s not uncommon for those in their sixties to juggle doctor’s appointments for two or more chronic conditions. Diabetes, heart disease, high blood pressure and arthritis can catapult a rather “healthy person” into a world of blood tests, self-administered blood pressure and glucose readings along with a multitude of medications. In all likelihood, specialists will treat each of these conditions, for example: a cardiologist for heart disease, rheumatologist for arthritis, endocrinologist for diabetes and an internist to monitor blood pressure and diagnose any new problems or make referrals to other specialists.

Each of them will likely order tests like x-rays, blood work, CT scans, MRI’s and they’ll prescribe medications to treat each condition. Unless, all of these doctors practice within the same health care system, they can’t access the results of each other’s test results. And, in some cases, unless the patient speaks up, they’ll order repeat tests unaware that it was ordered by some other treating physician. Or, if the patient doesn’t share his or her complete list of medications, a doctor may prescribe a medication that should not be taken with another drug or they may prescribe the same medication as has another physician. Thus, a patient may unwittingly wind up taking twice the dosage. Sometimes this happens, when a patient thinks a drug in a generic form is different from a drug written under the brand name yet it’s actually the same drug. Patients using multiple pharmacies are more at risk for this to occur because the pharmacist is less likely to pick up the duplication.

Here are some key findings of the survey that may alarm you:

• On average, 40 percent of the respondents reported that their doctors do not talk to them about potential interactions with other drugs or over-the-counter medications when prescribing new medications.

• Forty percent of those with multiple chronic conditions act as the chief communicator among the doctors they see because the physicians don’t talk to each other.

• Three out of four respondents really wish their doctors would speak to each other to better coordinate their care.

• One in eight respondents had to retake a test or procedure because the doctor or hospital did not have the earlier results.

• Three-quarters of heavy users of the health care system have left a doctor’s office or hospital confused about what to do at home.

• Three-quarters of adults 50 and older say they are worried that the quality of health care services they receive will get worse in the future.

• Twenty percent reported that they had to unravel conflicting information from different doctors.

So what about you? Do you have a story to tell or suggestion to make on how patients and doctors can better sort this out?

In the meantime, always keep an updated list of your medications and bring it to every physician visit to share with your doctor. Also, ask for copies of your test and procedure results and bring those with you to every doctor visit. Let the doctor know of your other medical conditions and the names of those physicians treating you. Bottom line? It’s all about you. You are in charge of your health care.

Elderspeak and Baby Talk: Same language?

All too often, in an attempt to be friendly or as a way of showing an elderly person they care, health care providers, retail clerks, hair dressers and restaurant servers, just to name a few, start talking in “elder speak.” People use this form of language when they assume that the older person they are talking to isn’t “all there” and probably can’t hear very well, either. In no time at all, they start dumbing down the conversation to a point where it almost sounds like “baby talk.”

If you’re wondering what elderspeak sounds like, here are some examples offered up by respondents on the “New Old Age” blog of the New York Times:

When asking someone their age, they ask “How many years young are you?”

Salutations often begin with “Hi sweetie, cutie, or honey.”

Actions, as simple as taking a pill, are evaluated like a grade school child with “Good job! Or good girl or good boy.”

A woman clearly in her seventies and older is referred to as “young lady.”

The nurse or doctor who asks her patient, “How are we feeling?”

Rather than asking about a career or current interests, an older person is asked, “Who were you or what did you used to be?

Greeting older people by their first name, as they would a teenager.


The overall tone of elderspeak is usually patronizing, over bearing and spoken slowly in a loud voice using simple words. The speech sends the subliminal message that the older person is incompetent. And here’s the thing: people pick up on it – even those with Alzheimer’s disease – and they don’t like it. They see it as insulting and a form of bullying.

New research shows that elderspeak, no matter how well intentioned by the speaker, is a lot more than an annoyance for those on the receiving end. Dr. Kristine Williams, an associate professor at the University of Kansas School of Nursing, analyzed hundreds of video tapped interactions between staff and residents who suffered from mild to moderate dementia. They identified if the staff used elderspeak, spoke normally or said nothing at all while they helped a resident with bathing, dressing, or grooming and then rated how residents reacted to the exchange. What the researchers found was sobering: when nurse aides used elderspeak, the residents resisted by physically pulling back, saying no, grimacing, grabbing the person or clenching their teeth. The more the residents became uncooperative, the more the staff resorted to talking to them like misbehaving children.

Dr. Mary Mittleman, Director of Psychosocial Research at the Silberstein Institute on Aging explains it this way: “It is a mistake to assume that a diagnosis of dementia means that a person becomes more like a baby. They may still have a lot of memories from far-distant times…they have a history which babies don’t.” She goes onto advise that ‘speaking to a person as an adult is probably going to get a whole lot more cooperation.”

It’s not just older people with dementia that are negatively affected by elderspeak. Anyone over sixty can be worn down by all the negative messages and images of aging conveyed in our culture, let alone as to how people talk to them. One major study showed that older people, who buy into these harmful perceptions and stereotypes, live 7.5 years LESS than those who ignore them and keep a positive attitude about growing older.

YOUR TURN

Share your elderspeak story. What's your pet peeve?

Dogs Making Hospital Rounds

Question: My mom is going into the hospital for a lengthy stay and hates the thought of not being able to see her dog. She begged me to ask her doctor if I could bring the dog in to see her in her hospital room. I’m afraid to ask. Is that even possible?

Answer: Believe it or not, your mom’s furry friend has a pretty good chance of being able to make a get well visit at the hospital. In fact, dogs are fast becoming new members of the medical team at hospitals in the region and throughout the country.

Over the years, plenty of research has shown the benefits of “pet therapy” for nursing home residents and children suffering from chronic and life threatening illnesses. As a result, it’s not uncommon to visit a senior care facility today and be greeted by the center’s dog, an aquarium in the lobby and a cat snoozing on the lap of a resident.

Studies show that blood pressure rates among humans are reduced when a friendly dog or cat enters the room and it goes even lower when people stroke or cuddle the pet. Researchers at UCLA Medical Center, Los Angeles, report that a short bedside visit with a therapy animal can ease anxiety levels by 24 percent in heart patients compared to a 10 percent drop when visited by a human volunteer.

People tend to smile and feel less stress and tense when “man’s best friend” enters the scene: And where best to reduce stress and anxiety but in an emergency room? That’s where you’ll find therapy dogs through Hershey Medical Center’s Pet Program coordinated by Cindy Wilson. “We’ve found the dogs offer a positive distraction in the emergency room, but you’ll also find them visiting patients in the ICU unit and throughout the entire hospital.” It’s not unusual for physicians to give her a call to “prescribe” a visit to a patient from one of the program’s therapy dogs. The program has become so popular among doctors that two of them actually volunteer with their own dogs.

Many hospitals throughout the country use therapy pets to promote the recuperation of their patients. It is more common for licensed therapy dogs to make patient visits with their owners who have attended training programs than having the patient’s pet come to visit.

But arrangements can be made for personal pet visits and, in your mother’s case, approach her physician and ask him or her to prescribe a recuperative in-room visit with her pet. The hospital will likely require that her dog is well groomed and verification from a veterinarian that the dog is up to date with vaccinations and healthy.

Besides the benefit of touch and positive emotional feelings that, in turn, strengthen the immune system; animal-assisted therapy can also make great gains in physical rehabilitation. One of Cindy Wilson’s favorite stories is watching a stroke patient being given a brush to groom a dog as a way for her to perform her physical therapy. She was much more motivated to reach and brush the dog rather than reach for a ball. It distracted her from the pain. “It’s so joyful to see how pets can touch a patient’s life,” exudes Wilson, “it’s not about me…I’m just at the other end of the leash.”

YOUR TURN TO SPREAD THE JOY

So for those of you who have a good natured pet and would like to spread the joy as a therapy pet volunteer visiting local hospitals, nursing homes, hospices and adult day centers here are some resources for you:

Contact Therapy Dogs International and they will identify a local dog evaluator for you and your pet to meet so they can determine whether or not your dog is ready for assisted pet therapy and what training is required.

Want to see a Youtube video on pet therapy?

Delta Society promoting the "Human-Animal Health Connection" is another great resource to find training in your area for you and your dog to become a volunteer

Also call your local hospital and ask for their Public Affairs Department to find out if they have a pet therapy volunteer program that you can join.

Credits: The photo is presented by Cape Fear Dog Training Club featuring one of their therapy dog hospital visits at Womack Hospital.

YOUR STORY

Please share your story as to how a pet helped you or a loved one recover from an illness. Send a photo, too! Or tell us about your volunteer story.

Physician Office Mistakes: Beat the Odds

The odds are mounting that you will be on the receiving end of a medical mistake resulting from your doctor’s office visit. If you want to weigh the odds, consider this: For every eight people that are admitted to the hospital, nearly 30 times that number visit a physician’s office. The average family physician sees 100 patients every week spending about seven minutes to listen, examine, diagnose and treat you. Two out of every three office visits result in giving patients pills and four out of ten order some type of diagnostic test (prescription mistakes and testing slip-ups are the leading causes of medical errors in doctor’s offices).

It’s not just the likelihood that you’ll be visiting a doctor’s office that places you at risk: there are not enough primary care physicians, appointments are getting shorter, and patients are seeing more and more doctors that specialize in body parts with no one coordinating their care. Most of the new safety practices and technology to prevent medical errors have zeroed in on the hospital setting not the doctor’s office.

Just a few weeks ago, a new report sponsored by the U.S. Agency for Healthcare Research and Quality along with the American Academy of Family Physicians uncovered just high how the odds are for medical errors at the doctor’s office. Here is what they found from 243 clinicians who reported close to 1,000 errors in a 32-week period: nearly one out of every five mistakes caused some type of physical or emotional harm to the patient of which half caused pain and suffering. The vast majority of cases (80 percent) lead to extra time and expense but did not adversely affect the patient’s health. Most mistakes were made in the process of ordering, performing and reporting test results. For example, the wrong tests were ordered, misfiled, lost, misinterpreted, not done properly or no one told the physician and/or patient the results.

So, if you want to reduce your odds, take these steps:

1. When your doctor orders a test (e.g. blood, x-ray, EKG) always ask what is
the name of the test, what is it for and when will you receive the results
and how?
2. Never accept, “If you don’t hear from us, then assume everything is okay” from
your doctor or nurse. Tell them you want to know the results whether it is normal
or abnormal.
3. If you have not heard from your doctor’s office on the test results when he or
she said they should be done, call and ask for the results.
4. Always bring a current list of your medications or better yet, bring the pill
bottles of all the current medications you are taking to the doctor’s office to
prevent prescription errors.
5. Ask for a copy of your test results and check them against what the doctor told
you he ordered.
6. Don’t be afraid to ask your doctor about the results and if you are making major
decisions on cancer treatment or surgery based on test results, ask your doctor
about having another pathologist or radiologist look at your tests for a second
opinion.

Medical care these days is more complex and overburdened. Despite all of this, most of the time your doctor is treating you mistake-free but it doesn’t hurt to become a safety-check partner, so you both can beat the odds.

YOUR TURN

Do you have a doctor's office mistake you want to share? Or a tip on how to prevent one? Click on the Post a Comment link below.

Want to know more? Check out the following articles and reports:
"Testing Process Errors and their Harms and Consequences Reported from Family Medicine Practices" by J. Hackner et al, Quality and Safety in Health Care 2008; 17:194-200.

"Test-Related Errors Uncovered in Family Practice Clinics," John Gever, Med Page Today, August 14, 2008.

"Danger at Your Doctor's Office" by Lorie A. Parch at Health.com

"Patient Safety in the Physician Office Setting" by Nancy C. Elder, MD, MPH

MEDICARE'S HOSPICE EITHER-OR CHOICE: IS IT FAIR?

Ever since Medicare decided – and wisely so – to cover hospice care they’ve forced people into making a tough choice: If you accept receiving hospice then you must refuse advanced medical care such as chemotherapy, radiation, transfusions or dialysis intended to extend your life or even cure you of your life-limiting illness.


Hospice focuses on caring for people physically, socially, emotionally and spiritually throughout their end-of-life treatment. The hospice philosophy is holistic supporting not only the person but the entire family. Medicare covers hospice for individuals with an incurable illness most likely limiting their lives to less than six months based upon a physician’s diagnosis. The Medicare Handbook states that the benefit includes covering drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare such as grief counseling. The care may be given in your home or a nursing facility if this is where you currently reside and in an inpatient hospice facility. Medicare hospice care also covers some short-term hospital and inpatient respite care to relieve a caregiver.

Even though millions would benefit from hospice care every year, large numbers walk away from the service because they don’t want to make the choice of either accepting hospice or rejecting life-extending care. “For too many of those patients, “that’s not hospice; it’s last rites,” counters Dr. John W. Rowe former CEO of Aetna in a recent NYT article. Regretfully, many people believe signing up for hospice care is a sign of giving-up all hope, so they hold-off making the choice and lose the opportunity to receive emotional guidance, pain management, and coordinated care during the most heart wrenching time of their lives.

Medicare beneficiaries can sign-up for hospice care, opt out in the middle of that care and then rejoin later with no waiting period imposed. For example, you may have advanced breast cancer and are receiving hospice care but you’re offered a round of radiation therapy to slow down the growth of a tumor that could hopefully extend your life by months. In this instance, you may decide that you’d like to try the radiation therapy forcing you to end your relationship and care with hospice. Or, perhaps a blood transfusion would bring you much needed energy and you’d like to enhance the quality of your remaining time. The revolving door approach is confusing to families and patients and greatly increases the likelihood of them falling through the cracks in an already fragmented system.

But times are changing. A growing number of hospice providers, experts and insurers believe that this either-or choice is unfair and outdated given new medical advances that were not available since Medicare began covering the benefit over twenty years ago. Hospices throughout the country and locally are exploring an “open access” concept allowing patients to receive the palliative care of medical and social support that have become the hallmark of hospice care and be given access to medical advances that can slow down the course of their disease. “We’ve had a few patients receive treatment such as radiation and chemotherapy while in our hospice and we’ve seen other hospice programs throughout the country exploring this new approach, too,” reports Karen Paris, LSW and Director of Hospice of Central Pennsylvania. “Its goal is to help patients make transitions in their care rather than make an either/or choice.” Open access proponents believe they will be better able to support patients and families struggling with a life-limiting illness who do not wish to discontinue certain treatment regimens.

But Medicare officials contend that if people can receive both curative medical care and palliative (soothing) care at the same time, then their costs will soar. Yet those in the field report that patients who are not in hospice tend to use emergency rooms much more because they don’t have the 24/7 advice of nurses and doctors who understand the course of the disease and can help families care for someone at home. As a result, patients end up in the hospital at much higher costs to Medicare and in the least favored setting for a dying person. Medicare doesn’t ban a hospice from offering advanced medical care – they just won’t pay for it. But what hospice provider can afford including chemotherapy or other advanced medical procedures on a $130 per diem rate for routine care no matter what the patient’s condition?

The other side of the debate is philosophical. If hospice’s mission is to bring holistic care and comfort to those who have accepted that their life is coming to a close then embracing treatments seen as life-saving or prolonging undercuts that acceptance. It sends mixed messages and interferes with their spiritual and psychological development towards achieving a peaceful dignified death. And it seduces families into accepting futile and unrealistic attempts that deny the inevitable.

YOUR TURN
Should Medicare stop forcing people to choose between hospice care and advanced medical care intended to prolong their lives? Or does the system work well as it stands now allowing people to opt out whenever they want and rejoin when they need to?

Hospital Acquired Infections Out of Control

A few weeks ago a historic report released by a state agency in Pennsylvania (PHC4) discovered that during 2005, over 19,000 patients contracted an infection while they were in the hospital which led to one in nine dying. Turns out, patients are almost six times more likely to die during a hospital stay if they acquire an infection than not. It is the first report in the nation identifying the rate of infections acquired by patients by individual hospitals. The Institute of Medicine, a few years back, found that at least 98,000 patients a year die nationwide from acquiring infections while they are hospitalized. Most experts believe this number is even higher.

Imagine if we put these numbers in the context of airplane crashes. Let’s say that only one-third of the infections could have been prevented – that’s just over 32,600 people or three plane crashes EVERY WEEK carrying 200 passengers each. Imagine the public outcry. Think the airlines could go on with business as usual? Think we’d still be flying? Or picture how you’d react tomorrow morning if the local headlines read that nearly 100,000 people were going to die of SARS in the next twelve months. Got your attention?

The industry tells us that hospitals, of course, are places for very sick people, and very sick people have germs. Doctors, nurses and technicians make contact in the most intimate of ways: via blood, urine and bodily contact. It doesn’t take much for germs to travel from one person’s hands to dozens of people every day. The problem for patients, however, is that their immune systems are weakened creating a “Welcome Mat” for bacteria. They contend that the severity of a patient’s illness is what increases the risks of getting a hospital acquired infection (HAI).

BUT health policy expert David Nash, editor of American Journal of Medical Quality and chair of the Department of Health Policy at Thomas Jefferson University, argues that, "It's the process, not the patients" that spawns hospital-acquired infections. According to Nash, three recent independent studies found that “despite hospitals' claim that in the sickest patients it's inevitable that someone is going to get a hospital-acquired infection, that's just not the case." Nash recommends that hand washing among hospital workers, carefully keeping surgical gowns and clothing sterile during procedures, reduced numbers of hospital personnel going in and out of operating rooms and more selective use of antibiotics could significantly reduce the alarming infection rate (Washington Post, 11/21). Marc Volavka, Executive Director of PHC4, is even more adamant: "The simple fact is that every patient who enters a hospital in Pennsylvania and in this country is at risk for a hospital-acquired infection. This is about flawed processes and the chaos currently existing within our health care delivery system."

YOUR TURN

1. Should hospitals require that every doctor, nurse and technician wash their hands in front of patients before examining or treating them? Should they tell patients on admission to ask hospital personnel, "Did you wash your hands?" Would you ask?

2. Should Medicare start linking its payments to hospital infection rates? For example, if someone gets a urinary tract infection that is hospital acquired, Medicare wouldn’t pay the hospital the added costs to treat the patient’s infection.

3. Should every state issue annual consumer reports on hospital acquired infections by hospital? Would you use this data to select a hospital for your next surgery?

Learn How to Prevent Hospital Acquired Infections

In response to the national infection crisis, the American Hospital Association (AHA), the American Medical Association (AMA), and the National Patient Safety Foundation (NPSF) advise that you can take steps to protect yourself in their brochure "Preventing Infections in the Hospital – What you as a patient can do."

They offer ten action steps you can take when you’re hospitalized. Here is what they recommend:

1. Wash your hands carefully after handling any type of soiled material and after you have gone to the bathroom.

2. Do not be afraid to remind doctors and nurses to wash their hands before touching you.

3. If you have an intravenous catheter, keep the skin around the dressing clean and dry. Immediately tell your nurse if the dressing becomes loose or wet. And (this is my recommendation) if your catheter is in for more than 48 hours, ask your doctor why and when it can be removed.

4. Let your nurse know right away if the dressing on a wound becomes loose or wet.

5. If you have any type of catheter or drainage tube, let your nurse know if it becomes loose or dislodged.

6. If you have diabetes, be sure that you and your doctor discuss the best way to control your blood sugar before, during, and after your hospital stay. High blood sugar significantly increases the risk of infection.

7. If you are overweight, losing weight will reduce the risk of infection following surgery.

8. If you are a smoker, quit. This reduces the chance of developing a lung infection and improves healing.

9. Prevent pneumonia by performing deep breathing exercises and getting out of bed.

10. Ask your friends and relatives not to visit if they feel sick. Make sure that all visitors wash their hands when they visit and after they use the bathroom.

Report it! If you ever acquire an infection, ask the doctor for the exact name and spelling of the infection. Also ask to see someone from the Infection Control Unit (every hospital must have one). Ask for an explanation of the nature of the infection, and what best practices are being used to treat it. If this infection has caused a real hardship for you, report the incident to your local health department. You may prevent someone else from going through the same thing since the Health Department will be obligated to look into your report and, if the hospital’s infection rate is above the norm, they will demand corrective action.

Where Infections Strike
Hospital-acquired infections commonly find their breeding ground in the urinary tract, around the wound of the surgical site, in the bloodstream and in the lung leading to pneumonia. The Pennsylvania Health Care Cost Containment Council PHC4 in their recent landmark study learned that wounds resulting from surgeries performed on the small and large intestine, and surgery for blood vessels account for the most frequent incidence of surgical site infections. Patients who suffer heart attacks or have peripheral artery disease are most likely to come down with pneumonia. Patients admitted with lung disease are more likely to acquire blood stream infections. And older patients are far more likely to suffer from urinary tract infections than any other age group. My guess is that this is related to higher catheter use prescribed for the elderly. In a recent study reported in the Journal of the American Geriatrics Society, researchers at the Veterans Administration Ann Arbor Healthcare System found that having a catheter in place for more than two days increases the likelihood of an infection at a rate of 5 percent each day. They found that, all too often, busy doctors with lots of patients simply forgot to give the orders to remove it.