Remaking American Medicine: The Stealth Epidemic

The third episode of the PBS series, Remaking American Medicine, entitled The Stealth Epidemic, was an examination of the financial and human costs that chronic conditions such as diabetes and congestive heart failure are having on the American medical system.

It is hard to believe that these conditions are affecting 100 million Americans—30% of the population—consuming 70% of health care resources and threatening to overwhelm the American health care system.

An interesting choice for a title, The Stealth Epidemic—an epidemic that is perhaps furtively spreading amongst the population and surreptitiously consuming health care resources.

The program looked at the initiatives of two health care systems attempting to transform patient care and health care spending, one in Los Angeles and the other in Whatcom County, Washington. Through the leadership of administrators and doctors, nurse-run clinics and nurse in-home visitations are attempting to educate diabetic patients about managing their disease.

While these initiatives are making an impact and should be championed, the problems of policy, politics and economics—an underlying current in this series—present numerous hurdles.

Proofreading and Internet Errors

While searching in BMJ Publishing's database, Clinical Evidence, I came across a spelling error of a drug name. Under the entry CHOP 21, a chemotherapy regimen used in treating non-Hodgkin's lymphoma, a drug named rituximab is mentioned under the 'Summary' section of this entry. In this paragraph rituximab is misspelled as 'rutuximab.' I had come across the drug elsewhere and was curious to see if there were two drugs with very similar names. I checked the MeSH database, e-CPS, EMBASE and STAT!Ref and found no entry anywhere for 'rutuximab.' However, if you 'Google' 'rutuximab' --- which was my first instinct--- you will get, as of this date, about 141 hits. Of course, if you search under the correct spelling, 'rituximab,' you will get about 958,000 hits.

It is interesting to see how errors can so easily proliferate on the Internet. And, as well, it is a cautionary reminder of how we must be attuned to detail, especially in such a field as medicine.

Fortunately, Clinical Evidence has the drug name spelled correctly where it counts, under the entry that specifically discusses the drug, CHOP 21 plus rituximab. I emailed them about the error but have not heard back from them.

Remaking American Medicine: First Do No Harm

The second installment of this program, entitled "First Do No Harm," was a two part examination of how the American health care system and health care providers are not doing all that they can to live up to the oath "first do no harm."

While it was reported that 98,000 hospital patients die annually in the U.S. because of medical errors, a further 90,000 die due to infection they contract while in hospital. Among the various antibiotic-resistant bacterium, methicillin-resistant Staphylococcus aureous (MRSA) and the battle against it in the Pittsburgh hospital system was the focus of the program. Because of the competitive nature of the American health care system, hospitals are less likely to share information with their competitors about their success. Such is the case with initiatives to reduce infection rates. For some in the health care system, such a stance flies in the face of the oath "first do no harm." One such doctor, Dr Richard Shannon, Chief of Medicine at Allegheny General Hospital in Pittsburgh, has lead the battle against hospital-contracted infections, reducing the infection rate from 49% to 6%.

The second part of the program focused on how information technology can reduce errors in patient care. The personal story that illustrated this issue was that of an elderly woman suffering needlessly because of a hand-written medication order being incorrectly transcribed. According to the program, less than 20% of doctors in the U.S. use computers in their work. One such hospital in New Jersey is endeavouring to change that, having implemented at $40 million computer network and training physicians to use it. Patient information is entered in one place providing everyone involved in her or his care easy access. Such systems also have the ability to alert health care providers to such things as harmful drug combinations. On a much wider scale, there are those who are advocating for a national health information network.

Palliative Patients and Spiritual Distress: The Roles of Health Care Providers

Part I (of III)

In her review article, “Role of the Doctor in Relieving Spiritual Distress at the End of Life,” Karen Pronk discusses the roles of health care providers in relieving the spiritual distress of palliative patients. Drawing on a large body of literature, Pronk offers some definitions of spirituality and explores the issues related to spiritual care as raised in the research.

Good palliative care, as defined by the World Health Organization, addresses all aspects of suffering—physical, psychological, social and spiritual. “Spiritual care,” Pronk states, “requires awareness of the patient as a person, in the sense that the person is defined by his [or her] past roles and relationships, hopes and dreams, and a creative inner self, as well as a body in need of repair” (p. 419).

How one individual defines spirituality can differ significantly from another. For some, spirituality is something understood within the framework of traditional, organized religion and a belief in God (or in a god), while for others, their understanding of spirituality is far removed from such concepts. It is something not easily defined, and, as Pronk suggests, this is even more so for some health care professionals—“to the scientifically trained mind, ‘spirituality’ is a bit like jelly—good if you can grasp it, but notoriously difficult to pin down” (p. 420; citing Whipp). Nonetheless, “spiritual awareness has been widely recognized as heightened in people who are faced with their mortality, and it occurs frequently at diagnosis of an incurable illness” (p. 424).

Pronk, Karen. "Role of the Doctor in Relieving Spiritual Distress at the End of Life." American Journal of Hospice & Palliative Medicine 22, no. 6 (November/December 2005): 419-425.

Remaking American Medicine (RAM)

Watched the first segment of the PBS broadcast program Remaking American Medicine: Health Care for the 21st Century, entitled "Silent Killer." For those of you who might have missed it, it was a moving and inspiring documentary. I am bit bewildered as to why it was broadcast at 4 pm on a Sunday afternoon. Perhaps KCTS had no control over that but it is a program that deserves a primetime time slot and the possibility of more viewers.

According to the program, as many as 98,000 Americans die in hospital each year due to medical errors. Medical errors kill as many people each year as breast cancer, AIDS and car accidents.

The focus of this first program was the initiatives around patient safety that were result of the death of a young girl and how her parents, particularly her mother, saw a way of making a difference for other patients. The Kings' daughter was only days away from release from the renowned John Hopkins Hospital Children's Center when she died of dehydration. Originally, she had scalded herself in the bathtub and was being treated for burns. Despite her parents' concerns that she didn't look well and she was constantly thirsty, staff at the hospital claimed she was fine.

One of the problems that came to light out of this young girl's death is the hierarchical, top down structure of hospitals in which patients and their families are on the bottom rungs. There was a lack of communication between doctors and nurses and a failure to take the concerns of the parents seriously. This last point is something my previous posting raised.

With the money they received from the hospital for the loss of their daughter, the Kings set up a foundation to fund initiatives that improved patient safety. As a result of the policies put in place at John Hopkins, many lives have been saved. Sorrel King travels around the country speaking to health care providers, telling the story of her daughter's death and inspiring providers and hospitals to do things differently. Because of her work, other hospitals have implemented policies to enhance patient safety.

While I expected this program to be an exposé on the failings of the American medical system, it was in fact a powerful illustration of people's ability to make a difference.

More information about RAM can be found at their website and information about the program series at the PBS website.

The Physician-Patient Relationship

One of the central issues of the article discussed in my previous posting is that of the relationship between physician and patient. Evidence-Based Medicine concerns scientific method, basing treatment on the most rigorously researched and substantiated scientific evidence. Patients deserve such treatment and physicians no doubt want to provide it. But patients aren't their disease; they have the disease. In the delivery of treatment, there is another element to be considered--the need for patients to be acknowledged and validated as individuals and recognize in their physician they have someone who hears them.

Amongst the literature that addresses this issue, is a recent article that, as the title suggests, may go right to heart of the matter: Improving education on doctor-patient relationships and communication: lessons from doctors who become patients. The author, Dr. Robert Klitzman, interviewed 50 doctors who had serious illness to determine in what way their experiences as patients impacted their work as health care providers. As a result of their experience as patients, the doctors reported "increased sensitivity to patients’ experiences and empathy in doctor–patient communication. These findings can help in teaching doctors to see more clearly that their specific point of view differs from that of patients, and can be limiting. This study also sheds light on the wide separation between intellectual and experiential learning, which needs to be addressed further in medical education and research" (p. 447).

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The route I took to find this article was through MEDLINE. I started my search using a good old fashioned concept: beside manner. One of the MeSh terms from which bedside manner maps is 'Physician-Patient Relations.' I combined this with another MeSh term: 'Empathy.'

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Klitzman, Robert. "Improving Education on Doctor-Patient Relationships and Communication: Lessons from Doctors Who Become Patients." Academic Medicine 81, no. 5 (May 2006): 447-453.

Health Care and Urban Aboriginals

In their research paper, " The Experience of Urban Aboriginals with Health Care Services In Canada: Implications of Social Work Practice," authors Ron Levin and Margot Herbert discuss the experiences of Urban Aboriginal Canadians as consumers of health care services, the lack of knowledge on the part of health care providers in treating such patients, and the implications for social work.

Some of the problems brought to the fore in their literature review centre around availability, accessibility and acceptability. While the issues of availability and accessibility often relate to the low socio-economic status of a large segment of the First Nations population, acceptability relates to the way in which health care services are offered. Treatment protocol can be incongruent with First Nations' cultural values and traditions and thus unacceptable. The lack of cultural knowledge on the part of health care providers translates into cultural insensitivity making communication between provider and patient problematic.

While this paper has more to say than what is presented here, it is with the implications for Social Workers that the authors conclude. Levin and Herbert state, "At a time when hospital social workers are attempting to create new roles and to acquire skills that will reinforce their usefulness in the hospital, there would be enormous “added value” if social workers could lead the way in bridging this very real gap in service for Aboriginal consumers" (p. 178).

I offer this brief summary as another perspective on the provisioning of health care and how health care information encompasses a vast range of issues.

Levin, Ron and Margot Herbert. " The Experience of Urban Aboriginals with Health Care Services In Canada: Implications of Social Work Practice." Social Work Visions from Around the Globe: Citizens, Methods and Approaches 39, no. 1/2 (2004) : 165 -179.