All posts by admin

Robotic Eyeball? New hope for retinal disease!

Seeing is believing! Awaiting FDA approval, a bionic eyeball gives hope to those with retinal disease and geriatric macular degeneration.  A high-tech  implanted eyeball receives messages from a pair of glasses equipped with a tiny camera, worn by the patient.  While not restoring vision, the inventors hope to provide enough sight “so a patient can walk down a familiar street without a cane or a guide dog.”  For more on this, see

June is National Safety Month

June is Safety Month –

Wear helmets while riding bikes, rollerblading, skateboarding and just helmetabout anything that might endanger your head. Safety Take care driving in neighborhoods and backing out of driveways.
#helmets save lives


Health Innovation – Right Here in Cleveland

#CLE has the Rock and Roll Hall of Fame, Cleveland Museum of Art, Cleveland Symphony Orchestra, major league sports and the list goes on and on.   But for physicians looking for a place to grow, Cleveland has it all, and world class hospitals to boot.  On May 26 our representatives will be on hand to talk with you about becoming a part of our vibrant Hospitalist team here in Cleveland.  Join us at the Global Center for Health Innovation and be amazed.

 Call Amy or Matt for more information 440-542-5000.  Global Center



Doctors- May 26 – Career MD –

Annual Event – Choose Cleveland for world renowned healthcare. Choose The Martin Healthcare  Group – leaders in Cleveland inpatient care for over 40 years!  Meet us at Career MD Event May 26th 5-8 pm The Global Center for Innovative Health. Call Amy or Matt @ 440-542-5000 for more information.  

May 26 - Copy

#CLE Join a Great Hospitalist Team in Northeast Ohio

Martin Healthcare Group offers the chance to work with interesting, motivated, responsible people in a hospital where you are valued and recognized for your contributions. We have been inpatient hospital leaders in the Cleveland area since 1975. Investigate our positions  in several prime hospital locations with beautiful parks, great schools, water sports galore and much much more!



Press Ganey Scores Start to Hit the Bottom Line


However enlightened or maligned, however irrelevant or indeed obstructive to quality medical care and whatever their inaccuracies regarding physicians, Medicare will use HCAHPS scores to justify lower payouts to hospitals for the services they render. Hospital administrators are beginning to tell us that if hospitalists’ satisfaction scores are not good and are not at the level that prevents lower compensation they expect to make up that financial penalty by passing it on to us. Some hospital administrators whom I have encountered are taking a position that we are the “stewards” of patient satisfaction and thus responsible for achieving “top box” responses regarding physician questions for all the physicians the patients encounter.

This is just fact. At one of our facilities the Chief Medical Officer has created a paper check list of physician behaviors for the hospitalist to complete after each patient encounter. It looks like this:Questions
The doctor, date and patient MR number are self-explanatory. The physician is then expected to place a check mark next to the listed words, “Did you complete the following required tasks: Sit at the bedside? Listen to the patient? Ask the patient about his/her comfort? Explain the clinical situation in a way the patient could understand? Did you inform the patient that he/she might receive a survey regarding their care in the hospital?” The doctor is then supposed to ask the patient if there was any aspect of his/her care that they would not consider excellent and assure the patient that they will attend to the matter.

After a certain time this “self-graded test” of current doctor behavior will be measured against patient satisfaction scores prior to this checklist to determine if it improves patient satisfaction scores. The doctors are also strongly encouraged to ask patients if they can “clarify anything any of their other doctors have explained to them”.

I am sure the above is not unique to this hospital. I do not have any problem with expecting hospitalists to sit down with all patients, listen to them closely, ask if there is anything that might be accomplished to explain to them more clearly or make them more comfortable. I have been teaching people this for a long time.

I do have a problem with explaining to patients about surveys, or solving issues over which physicians have no control. I doubt that we can sincerely state to patients that the fact that their food was cold or they were not comfortable waiting for an MRI is something that we can address. Our services to patients must be professional and personal. Shilling for a higher score from a patient at the end of an encounter seems less sincere than simply asking them, “Have we taken good care of you here?” or “Has your care been excellent here?”

In any event, the above information is factual. Patient satisfaction scores will not go away.

I am surprised when I round with doctors how little some seem to know about Press Ganey questionnaires. The questionnaires are full of questions regarding the hospital but there is only a tiny set of questions regarding doctors: “Did you treat the patient with courtesy and respect; did you listen to their questions and concerns; and did you explain to them their conditions and treatments in ways that they could understand?” That is it. And the only answer that counts is “always”.  That is the “top box” score that is referred to. If the patient checks the box next to “most of the time” or “some of the time” your score is zero.



Patients on Chronic Narcotics: The Hospitalist’s Dilemma

admin-ajax  In my role as Director of Patient Experience I recently met with a pair of physicians at one of our hospitals. Before we began discussing how best to serve our patients, they forcefully and adamantly brought up an issue which causes them great frustration and consumes their daily rounds.  The issue, written about extensively and often satirically concerning patient satisfaction, is the conflict between hospital physicians and patients who are chronic opiate users.  They discussed how that plays out in the context of hospital administrators looking for high patient satisfaction scores and some nurses who advocate liberal dispensation of narcotics to patients with chronic conditions.

The background of this is a current epidemic of narcotic abuse, narcotic related death and narcotic mis-prescribing in the U.S.  Deaths from prescription opiate medication have quadrupled in the U.S. over the last fifteen years (this figure does not include deaths due to cheaper opiate medications purchased on the street.)

The physicians who spoke to me felt that the problem starts in their community, where local physicians very liberally prescribe narcotics and benzodiazepines on a chronic basis to their patients.  The physicians argued that these patients when admitted for various conditions not related to pain demand an upward dosing of their oral narcotics to intravenous narcotics in the hospital. The physicians noted that this intravenous narcosis began in the emergency department, sometimes with disastrous results of respiratory depression, and they implied that this was done because the emergency department staff was worried about their patient satisfaction scores. I express their opinions, I do not assert fact.

These physicians further felt that the nursing administration and medical leadership of their hospital frustrated them in their attempts to curtail chronic administration of opiates to patients in the hospital who did not have malignant pain, thus furthering a cycle of addiction within the community.

These physicians felt they had no allies within the hospital or the community that might enable them to become part of the process of addressing the narcotic abuse epidemic within that community.

Hospitals and health systems have successfully addressed this problem. It has been extensively documented, studied and chronicled.  There are solutions. We now have the most current and very recent Centers for Disease Control guidelines that favor non-narcotic approaches to chronic pain other than malignant, usually oncological, pain.

  My advice to anyone considering patient satisfaction scores is to state unequivocally that issues of patient safety and good medical practice always always trump any issue regarding patient satisfaction.  This is a line in the sand.  No physician should, under any circumstances, prescribe anything or communicate anything that is not in the best interests of the patient in order to elevate patient satisfaction scores.

   In a perfect world of hospital medicine, and given the enormity of the public health problem that is narcotic dependence, each hospital would convene a working group of involved staff, from emergency staff, primary care systems, hospitalists, pharmacists, nursing staff and care coordinators to devise a means of addressing the issue of narcotic administration. They would cooperatively develop hospital guidelines for the use of narcotics for the patients in any part of the institution who are current chronic opiate users.  Recognition that the use of narcotics for chronic non-malignant pain should be subject to CDC guidelines would have to be foundational in seeking clinical pathways forward in managing this problem.

In the short term, hospitalists’ groups can devise their own means of developing uniform approaches to the problems related to the treatment of hospitalized patients who, as outpatients, are chronically habituated to narcotics.

We must start with the understanding that chronic narcotic dependence is a disease.  However it came about, it is an addiction that is not unlike other categories of addiction such as tobacco or alcohol dependence.  Patients with these problems do not benefit from shaming, scorn or moral condescension. These problems know no class or gender boundaries.  Consider that some of the stars in the constellations of people who revolutionized medical thinking were addicts: Sigmund Freud painfully freed himself from cocaine addiction.  Halstead, who spent his life advancing surgical science, struggled with cocaine and morphine addiction.

We must recognize that as hospital-based physicians we have limited exposure to these patients and cannot within a short hospitalization period attempt to resolve their dependence.  It is not reasonable in most cases that we can expect to detoxify these patients while they are in the hospital.

That being acknowledged, we can attempt to limit narcotic administration to them and not escalate their dosages.  This will entail personal interactions with the patients in which we directly address the fact that they are habituated and that we feel that habituation is dangerous to their long-term health.  The use of the “I” statements in these conversations is helpful: “I see that you have been using narcotics for a long time for your chronic problem and I am afraid that the long term effects of this are injuring your health.  In addition to that I do not want to prescribe more narcotics to you because I am afraid it might harm or even be fatal to you.  I have seen people die due to excess narcotic prescription…”

We should not forget that we can forge alliances with competent pain management physicians, primary care physicians and others in individually managing these patients.

Finally, we are under no obligation to supply outpatient prescriptions of narcotics to patients when they are discharged.



From the desk of Dr. Kibbe… “Rhetoric and Sincerity”

Rhetoric and Sincerityadmin-ajax

America seems captivated by a cult of individualism and individual responsibility.  We tend to look upon our individual prosperity and health as outcomes of individual actions and choices.  While complex social situations including blind luck and happenstance create our individual realities regarding our fortunes and our physical health, we continue to place emphasis on our individual choices and behaviors as most the most important factors defining us.

Regarding our physical health I think we have a bias that tends to look upon the ill as personally responsible for their illnesses.  If not personally responsible for illness etiology, they are accountable for illness outcomes and the means of recovery. I think this bias is central to our singular failure in the US, to protect all citizens against the misfortunes of disease via a form of social medical insurance.

Strangely we do not deny medical insurance to the elderly.  In fact, we seem to very much support it.  To the younger population, however, many seem ambivalent or hostile to the same provision.  For younger people struck with catastrophic illness we appear to be untroubled that they may become fodder for the bankruptcy courts.  We tend to blame their fate upon their perceived individual failures.

Yet in dealing with the infirmities of the elderly there are many about them, including family, who blame them for the individual failure of becoming ill in old age.  It is a subtle and complex social dynamic, but I believe it is born out of our cultural mythology of individual responsibility.

Who among us in caring for an eighty or ninety-something with multi organ failure has not been confronted by family members who are shocked and stunned at the failure of the patient? Often we see family members vexed at the intractability of pulmonary or cardiac failure in their parent.  We sense certain anger in them that the patient will not eat, cannot tolerate a small measure of physical therapy or cannot recover. Often they say they want these things “fixed.”

I think that unwittingly, the language we use to describe the elderly and failing patient fuels the false expectations of some family members.  We describe patients as “having” a particular disease.   The patient has (the verb conveying ownership) heart failure or pulmonary failure or kidney failure or dementia.  This implies that the patient needs to do something about it or the physicians need to fix it, either action being probably impossible.  We also thus decontextualize the patient—there is nothing in our statement that distances the eighty seven year old patient from the fifty seven year old.

“Rhetoric” is the art of persuasive speaking.  While we cannot change the cultural norms surrounding us, we can change our rhetoric, the way we describe pathology, to be kinder to the patient and more accurate to the bewildered family.

If your very elderly patient has heart failure and you say, “His heart is failing him,” rather than “He has heart failure,” it is accurate and places the onus of failure not on the patient but upon the heart.  If you say, “His aged heart is failing him,” further accuracy is conveyed.  If you say of the patient that “His mind is failing him due to the terrible disease of dementia,” you convey a more accurate summation of the problem than the statement, “He has dementia.”

If a patient has end-stage pulmonary disease you can describe it as such and remark that it will be terminal; but if you say, “Her lungs are failing her and I am afraid it is too much for us to expect her to recover from that,” your utterance is one of empathic sincerity.  “She fights to live but her lungs have failed her in that fight.” Of the very frail and cachectic man who cannot become ambulatory again after hip fracture you might observe, “The poor fellow is so frail and so much of his muscle mass has over time just left him; I do not think it is fair for us to expect him to get it back.”   Of course many family members will not need this thought correction.  I suggest you use it always, however.

When I was a student I was fortunate to study for some time in Scotland.  In the above I am paraphrasing what I heard often expressed to medical teams by concerned family members regarding their elderly of more than a generation past.  I recall one wife’s observations regarding her aged husband.  It went something like this: “The poor wee thing is so frail and he will be taking nought; no nourishment, not even if it were the very best.  His life has been long, and hard—fought in Africa and Italy, did he not?  But he has gone from 12 to 9 stone these months, no matter what I do.  His poor heart is tired and his life has been long.  You willnae be troubling him with anything crazy, I hope.”

The wisdom of that generation, the one that faced near starvation in the Great Depression, the bombing and burning of their cities in the war that followed and near economic ruin in the following peace, was one that embraced sincerity and reality.  Perhaps we should emulate it.