Back in the days when I was training, medical students had to study Latin in order to achieve fluency in the language of medicine. Today, it seems, doctors are learning an entirely new lingo consisting of buzzwords and business speak! According to Pamela Hartzband and Jerome Groopman, two Harvard Medical School / Beth Israel Deaconess Medical Center physicians, current healthcare reforms mean that hospitals are becoming factories and clinical encounters are becoming little more than economic transactions. Writing in the latest edition of the New England Journal of Medicine they claim that, “Patients are no longer patients, but rather ‘customers’ or ‘consumers’. Doctors and nurses have transmuted into providers.” The combination of the ongoing economic crisis and efforts to reform the health care system have resulted in many economists and policy makers proposing that patient care should be industrialized and standardized and that hospitals and clinics should be run like modern factories. At the sane time, archaic terms like doctor, nurse and patient are being replaced with terminology that fits this new order. In the process, the special knowledge that doctors and nurses possess and use to help patients understand the reason for and remedies to their illness get lost in a system that values prepackaged, off-the-shelf solutions. “Reducing medicine to economics makes a mockery of the bond between the healer and the sick,” they write. Hartzband and Groopman say the new emphasis on ‘evidence-based practice’ is not really a new phenomenon at all. ‘Evidence’ was routinely presented on daily rounds or clinical conferences where doctors debated numerous research studies. Back then, the exercise of clinical judgment, which permitted the assessment and application of data to an individual patient, was seen as the acme of professional practice. Now, health policy planners, and even some physicians, contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints. Even more troubling, the authors suggest, is the impact of the new vocabulary on future doctors, nurses, therapists and social workers who care for patients. “Recasting their roles as providers who merely implement prefabricated practices diminishes their professionalism. Reconfiguring medicine in economic and industrial terms is unlikely to attract creative and independent thinkers.” When we are ill, we want someone to care about us as people, rather than as paying customers. Despite the lip service paid to ‘patient-centered care’ by the forces promulgating the new language of medicine, their discourse shifts the focus from the good of the individual to the exigencies of the system and its costs. Should we celebrate the doctors whose practices maximize profits or those who show genuine concern for their ‘customers’ or better still patients? Let us know what you think.
How many of you have been settled, albeit uncomfortably, at 30,000 feet enjoying a movie or hastily putting the finishing touches to the PowerPoint presentation you are due to give in a couple of hours when you hear a familiar chime, followed by the flight attendant asking: “Is there a medical professional on board this aircraft?” Every year, more than 500 million people travel by air in the U.S. Not surprising then, that medical emergencies aboard aircrafts occur. In fact, an estimated 1:10-40,000 passengers will experience one. With commercial air traffic increasing, these emergencies are expected to become more frequent, especially as the percentage of older people increases. Although flight attendants are required to undergo initial and recurrent training on aviation medicine, first aid, CPR and automated external defibrillator (AED) usage every 12–24 months, EMTs, paramedics and other medical professionals are still called upon to provide assessment and treatment of passengers who become ill in flight. Now, two U.S. physicians from Boston’s Beth Israel Deaconess Medical Center have called for a standardization of the processes and the equipment for dealing with in-flight medical emergencies. Within the current issue of the Journal of the American Medical Association, Melissa Mattison, MD and Mark Zeidel, MD, note that the kinds of approaches that have improved flight safety have not been extended to providing optimal care for passengers who become acutely ill while on board airplanes. Each airline has its own reporting system and protocol. And while emergency medical kits are mandated to contain medications and equipment, actual kits vary by airline. As a result, paramedics and physicians responding to emergencies can face a broad array of challenges including cramped physical space, emergency kits whose contents are unfamiliar, inadequate, and poorly organized, and flight crews unaware of how best to assist the physicians. Mattison and Zeidel offer a four-step plan to improve the treatment of passengers who become ill in-flight:
- A standardized recording system for all in-flight medical emergencies, with mandatory reporting of each incident to the National Transportation Safety Board. This approach should include a systematic debriefing of anyone directly involved with the in-flight medical emergency.
- Airlines should create a standard emergency medical kit with identical elements available in identical locations on every flight.
- Enhanced and standardized training for flight attendants, including the clear obligation that a single flight attendant is assigned during emergencies and stay nearby until the patient is safe.
- Standardized flight crew communication with ground-to-air medical support available on all flights when there are no health care professionals available.
As both a frequent flyer and paramedic, I applaud the authors for this long overdue common sense approach. Have you ever helped with an in-flight emergency or perhaps been the victim of one? If so, SRxA’s Word on Health would love to hear from you.
Technology has placed vast amounts of medical information literally a mouse click away. Indeed, 57% of Americans say they get their primary medical information from the internet. Maybe that’s because, an individual’s main potential source of information, the doctor’s notes, taken after a visit are not traditionally part of the discussion. Such records have long been out of bounds.
After patient encounters, doctors have long written notes ranging, from cryptic abbreviations on an index card to lyrical essays. Yet despite a patient’s legal right to read their doctor’s note, few do. Although literature suggests that promoting active patient involvement in care may improve doctor-patient communication and clinical outcomes, both patients and doctors express everything from enthusiasm to dismay when it comes to sharing the visit note.
In Open Notes: Doctors and Patients Signing On, researchers speculate about the risks and rewards of making clinicians’ notes transparent to patients. “Opening documents that are often both highly personal and highly technical is anything but simple,” say the investigators from Beth Israel Deaconess Medical Center.
Their OpenNotes study will include more than 100 primary care doctors and 25,000 patients who will be invited to read their notes. Some primary care doctors interviewed as part of a pre-study assessment “…anticipated both clinical benefits and efficiencies from incorporating laboratory findings and recommendations into the note, thereby obviating the need for a follow-up letter.” They hoped for improved patient education and more active involvement by patients in their care.
On the other hand, some doctors “worry first and foremost about the effect on their time, including calls, letters and e-mails as patients seek clarifications, disagree with statements, or correct what the doctors consider trivial errors of fact.”
Others were concerned they would have to leave out important information, omit frightening diagnostic or therapeutic considerations, or that patients would not understand that ‘SOB’ stood for ‘shortness of breath.’ And some were simply embarrassed about how they write!
From the patient perspective, views are also somewhat mixed. For some of the patients, the dialogue inherent in the process was appealing. On the other hand, some clearly do not want to read what their doctors write because they are worried about discovering something they would rather not know, finding potential diagnoses that might make them anxious, or reading what their doctors really thought of them.
The study will use secure Internet portals and only include notes written during the trial period. While they are gathering considerable data from the patient and doctors’ experiences during the study period, investigators say their ultimate question is whether the participants will want to leave the OpenNotes switch on after 12 months.