Category Archives: Issues of Interest

Uncomfortable Conversations

In 2014 Ohio won the shameful honor as “ground zero” in the Opioid Epidemic.  In that year 2,106 deaths occurred in Ohio due to opioid overdose (Cleveland.com November 30, 2016), more than any other state in the US.  California, a state with more than 3x  the population of Ohio, came in second.

I often ask young doctors, “What is your most uncomfortable conversation with your patients?” The most common answer I receive is not relaying prognosis or abnormal test results.  Overwhelmingly, the most uncomfortable conversations with patients are with those who are seeking opiates. I often ponder regarding individual solutions. But before solutions, we must identify sources.  Without avoiding advice on individual physician responses to patients demanding opiates let me first consider how we, institutionally and socially, find ourselves in these uncomfortable conversations.

As a start, the fact that there is an opiate overdose/abuse epidemic still seems to be a dead elephant in the living room for most emergency department personnel and what they do to patients in many ways sets the stage or scenario in which we later find the patient.  When I speak to ED physicians about the issue they appear to be aware of it but I cannot see that it changes their practices.  Thus the number of patients administered hydromorphone in the ED, usually given IV (which produces a euphoria akin to heroin), for questionable complaints of pain does not appear to be diminishing.  The patients then arrive on the floor primed with the expectation that this euphoric state will be maintained by the staff on the floor.  Most ED practitioners appear to have forgotten that all the drugs that we give for pain can be given subcutaneously and that there are modalities to address pain other than opiates.  Many ED physicians are afraid that their masters at the corporate level will penalize them for any patient complaints should they refuse the patients who “know” they must have opiates like Dilaudid (often with a little Phenergan on the side).  This scenario, in which a person with chronic pain or pain far out of proportion to clinical, radiographic or laboratory findings is treated with potent intravenous narcosis, is the one which most frustrates me.  To me it is one of the ways we initiate or enable addiction.

We could perhaps make history by being the first hospitalists to campaign to convene a mandatory meeting, followed by periodic mandatory meetings, of all hospitalists, all ED practitioners, pharmacy staff, nursing leaders and administrators to review narcotic usage in the hospital, both on the floors and in the ED, with review of any events such as respiratory depression or delirium induced by opiates.  The expressed purpose of such meetings could be “Intervention into the Opiate Crisis; “(Hospital’s) Role in Preventing and Addressing Opiate Abuse.”  The burning issue behind this demand would be the fact that thus far in 2017 a person in Cuyahoga County dies every other day from an opiate overdose.

As you may have discovered already, medical practitioners across the country are involved in similar institutional efforts.  If you google “reducing narcotic use in the emergency department” you will find a bounty of guidelines and articles describing successful efforts at all sorts of levels to help practitioners kick the habit of opiate prescription (pun intended.)  I like “An ER Kicks the Habit of Opioids for Pain,” found in the New York Times, 10 June 2016, which describes how a New Jersey Hospital Emergency Department cut their opiate use by 38%.  Harm reduction strategies are easy to find, constructed by institutions or various medical societies.

Harm reduction on the street is perhaps a way of framing your discussion of opiate intake with a person who clearly is seeking opiates that are inappropriate in their treatment.  At times, because the opiate epidemic is so potentially fatal, I go straight to questioning patients about what is the greatest threat to their lives, the intravenous use of street drugs, and simply ask them if they do that.  If the answer is affirmative, I then try to give them the lecture about how to reduce risk of death from overdose and complications of infection.  At SHM and other websites you can find detailed discussions about how iv drug abusers “cook” and administer their drugs and how to advise them to do so in the least harmful way, including procurement of clean needles and Narcan.  Most physicians do not know how iv drug abusers go about preparing their drugs for iv injection and an understanding of this is informative in comprehending the infectious complications we encounter as well as in advising addicts on how to avoid death and infection.

The issue of how to deal with the patient seeking inappropriate narcotics rapidly balloons outward from our need to protect the individual patient to the necessity of addressing and influencing a national medical epidemic of preventable death.

Peter S. Kibbe, MD FHM
 

 

 

 

Better Than Winning the Lottery

lottery-balls-cashWhen the recent Power-ball Jackpot rose to $1.58 Billion dollars recently, millions lined up for tickets, hoping to beat the odds.   But here’s a surer way to “win,”  at least to keep from spending millions, in your lifetime: QUIT SMOKING.    According to a January 19th CNBC report , “Smoking could cost you more than $1.6M  over a lifetime.”    The 66 million tobacco smokers in the US spend  hundreds of billions every year, for tobacco and illnesses related to it.

While winning the lottery can be a fairy tale, a lifetime of smoking related death and illness is real.  It is estimated that nearly $170 Billion in direct health care costs are incurred and more than $156 billion is lost  in productivity due to premature death and secondhand smoke exposure.”

Why play the Lottery with our lives?  The odds are much greater if we quit.

For the entire article, see http://www.cnbc.com/2016/01/19/smoking-could-cost-you-bigtime-over-a-lifetime.html

 

Physician Safety Often Overlooked

internal-safety-auditFor healthcare professionals  #patientsafety is always #1, yet  many ignore risks to their own health,  often viewing themselves as immune from the dangers of their profession.  Doctors and nurses have proverbially  risked their  lives for the cause of the sick, but when risks are preventable, precautions must be addressed.  To read more from Ann Beekman, BSN and cath lab manager, see:

http://www.hospitalimpact.org/index.php/2015/05/07/when_it_comes_to_safety_hospital_leaders?

Hospitalist Quality Pays Off in Payouts

results #Hospitalists and their teams play a vital role in  Affordable Care Act & Medicare incentive payouts.  In a recent issue  of The Hospitalist, Winthrop Whitcomb MD, MHM , explains that hospitalist teams with a penchant for performance are most keenly positioned  to reduce revenue risk & ensure positive results for their hospitals.   For more of this article, see http://www.the-hospitalist.org/article/much-ado-hospital-quality/2/

Length of Stay Dilemma

@TodaysHospital  Stella Fitzgibbons, MD speaks of the fragile balance between LOS initiatives and comprehensive diagnosis of patients admitted via the emergency room. In   “A rush to discharge?” she aptly defines the hospitalist’s dilemma: To placate the record keepers but always put the patient first.  To read the whole article, see:   http://www.todayshospitalist.com/index.php?b=read_blogs&cnt=10231&author=Stella%20Fitzgibbons,%20MD

Length of Stay vs Readmission – Catch-22?

clock is tickingHospitalists face a dilemma:  With penalties for lengthened stays and consequences for readmissions, physicians are often “darned if you do, darned if you don’t.”  In her blog, Stella Fitzgibbons, MD writes: “A rush to discharge? “
Your hospital has announced a “length of stay initiative” accompanied by e-mails and presentations at staff meetings in which you’re lectured about hospital-acquired infections, thromboembolism, deconditioning and all the other bad effects of prolonged hospitalization. But the bottom line is, well … the bottom line: Medicare and Medicaid keep an ever-more watchful eye on “avoidable days” complete with penalties, and other payers are cracking down on over-long stays too. – See more http://www.todayshospitalist.com/index.php?b=read_blogs&cnt=10231&author=Stella%20Fitzgibbons,%20MD

2015 Concerns for Physicians and Patients

2015Boston-based @PhysiciansFound released a list of five issues that will affect both physicians and patients in 2015. In summary, 2015 concerns are:
1) Consolidation: smaller hospitals will continue to be “gobbled up” by larger systems – Physicians fear their clinical autonomy and decision making will be compromised by the cultures of larger systems.
2) Physicians/Patient relationships Highly valued patient relationships and communication are at risk due to increased demands on value based reporting in lieu of bedside presence. To keep patient’s care at forefront, Physician’s must become more efficient in addressing patient needs.
3) ICD-10 preparedness – 75% of physicians responded that revisions will complicate coding and efficiency.
4) Transparency needed in Medical billing– it complicates decision making and is confusing and frustrating for patients.
5) Physician shortage – Over the next few years, thousands of physicians will retire or reduce their patient care hours. This raises concern for hospitals, patients and especially for physicians, who will bear the burden of caring for more patients with less support.