Tuesday, December 5, 2023

Lessons learned the hard way

The practice of medicine is a great teacher. I admit I have made mistakes; however, I have tried to learn from the errors I have made. In this blog, I will share three stories of blunders and the lessons learned from these errors.

One of my best learning experiences occurred in 1976 when I was a junior resident in urology at Baylor College of Medicine in Houston. I was assigned to a pathology rotation, where my job was to process specimens taken at surgery, dictate a gross description of each specimen, and then place them into the cassettes used to make the permanent sections.

While I was transferring a prostate biopsy, it slipped from the forceps and was washed down the drain of the sink. I took the drain trap apart and searched for the 0.5 mm x 10 mm (1\6 inch by 1\2 inch) sliver of tissue, but I could not locate it. I felt terrible and shared the news with the director of the pathology lab, who recommended that I report what had happened with the biopsy to the urologic surgeon, Dr. Herbert Seybold.

I called Dr. Seybold, and he told me to meet him in the lobby of the hospital at 4 P.M. I worried what would transpire at that meeting. I even imagined that I would be reported to the program chairman and might be asked to leave the program.

Dr. Seybold was in the lobby promptly at 4 p.m., and together, we walked to the business office. He asked for the head of the department and explained what had happened. He wanted to repeat the procedure the following day and asked not to charge the patient for the extra day in the hospital or for the second operating room procedure, as this was a problem caused by the hospital and was not the patient’s fault.

We then went to the operating room and met with the head of anesthesiology whom we asked if the department would not bill the patient for the anesthesia for the second procedure. The anesthesiologist was very sympathetic, and he agreed to waive the additional fee.

Then we went to the patient’s bedside to inform the patient of the event. Dr. Seybold sat down beside the patient and explained that the specimen was lost. He did not blame me but did state that the specimen was lost in the pathology lab. He told the patient that the procedure would be the first case the next day and that he would ask the lab for an expedited reading of the slide. The patient was disappointed but agreed to the plan of action as presented by Dr. Seybold.

Dr. Seybold then took me to one of the private conference rooms and told me that what I had just witnessed was the proper way to handle a complication. He told me that all physicians can expect complications and that mistakes will be made. He said the best way to manage these issues is to be forthright and honest, tell the patients the truth, and accept full responsibility. Patients will understand an honest mistake if the doctor is truthful. It is when doctors make excuses or falsify the facts that patients become angry, hostile, and litigious. Rarely will a patient become a problem if the doctor tells the truth.

I have passed this invaluable lesson on to medical students and residents whom I have mentored over the years. This advice worked well many years ago and is still good today. I believe Dr. Seybold’s message will be helpful to every doctor who is confronted with a problem or a complication.

The rest of the story: What happened to the patient? I accompanied Dr. Seybold to the operating room for the second procedure, hand-carried the tissue sample to the lab, and oh-so-carefully placed it into the appropriate cassette. The final path report was benign, and all three of us — Dr. Seybold, the patient, and I — breathed a sigh of relief.

So, the take-home message of this story is to always tell the truth. There may be consequences for telling the truth, but they will be less than if you withheld the truth and caught in a lie. People will respect you for the truth, and seldom will you burn a bridge for your honesty.

The second story involves a relationship with a pharmaceutical company. I had several conversations with the director of marketing, and he was to get back in touch with me regarding a project. I didn’t hear from the director after sending him multiple letters and emails, including a FedEx letter.

Feeling frustrated by not having a response, I wrote him a letter stating that if I didn’t receive any follow-up, I was going to contact the president of the company and relate my experience and the director’s lack of follow-up.

Shortly thereafter, I received a call from the director’s secretary stating that his wife had terminal breast cancer and that he had taken a leave of absence to care for his wife.

I felt terrible about my overreacting and not knowing all the information about his dire situation. The lesson I learned is to get all the information before coming to a conclusion or before acting. Had the secretary contacted me and told me that the director took a leave of absence for personal circumstances, I would have understood and dropped my request for follow-up. Since that didn’t happen, it taught me to first obtain the necessary information and then act. I should never act without obtaining the reason behind the situation.

Finally, a lesson about putting your foot in your mouth and speaking when you don’t know all of the information.

I was caring for an elderly male patient, and he was accompanied by a much younger woman. When I walked into the room, I introduced myself to the lady and I asked, “Are you his (the patient’s) daughter? She replied with a lovely smile, “No, I am his wife?” Lesson learned: don’t make assumptions. It was not pertinent to know their relationship to care for his medical problem. When in doubt zip it!

Well, I hope these three stories provide some examples of managing a mistake or error and when it is necessary to have more information before speaking or writing. If you have any stories that you would like to share about lessons learned from your patients and your practice, please let me hear from you, doctorwhiz@gmail.com.

___________________________________________________________

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.

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Monday, December 4, 2023

There’s a crisis in men’s health: What practices should do

According to the CDC, a man’s life expectancy is 5.8 years shorter than a woman’s – 73.5 years compared to 79.3. Men are more likely to die of cancer and diabetes, and they are more than twice as likely as women to die of drug overdoses. Further, men die from suicide at nearly four times the rate of women, according to the American Foundation for Suicide Prevention.

We may be experiencing an epidemic of male isolation. In 2021, 15% of men reported that they had no close friends, compared to just 3% in 1990. Plus, only 22% of men reported reaching out to their friends during tough times, down from 45% 30 years ago. This lack of social connection doesn’t just impact men’s mental health, but it has serious physical consequences as well. In fact, a recent study found that people who experience social isolation have a 32% higher risk of dying early from any cause.


Factors that influence men’s health


Overall health is influenced by a variety of factors, both genetic and environmental. Many of these are outside of an individual’s control, such as genetics and hormones. Men’s XY chromosomes and higher levels of androgens make them more susceptible to certain diseases. For instance, heart disease typically begins 10 years earlier in men than it does in women.

However, lifestyle also plays a significant role. Men tend to take more risks than women and are overrepresented in more dangerous jobs. They are also more likely to smoke, drink to excess and abuse illegal drugs. Moreover, men often lack strong interpersonal relationships and support networks. These social and behavioral factors add up over time, leading to poorer health outcomes and shorter lifespans for men.


Men aren’t using healthcare services


Among those poor lifestyle factors: men are far less likely to visit healthcare providers. In a survey by the Cleveland Clinic, 65% of men reported that they avoid going to the doctor as long as possible. The CDC also found that men visit their physicians less frequently than women – 224 visits per 100 men in one year compared to 308 visits per 100 women. Skipping routine screenings means men are missing the opportunity to diagnose medical conditions before they become more serious.

Men are also less likely to utilize mental health services. In fact, 40% of men have never spoken to anyone about their mental health. This reluctance to pursue treatment is likely due to social expectations around masculinity – where self-reliance is valued and getting help is seen as a sign of weakness. Further, men cope with mental health challenges differently than women, tending to minimize symptoms and self-medicate with alcohol or drugs.


How healthcare providers can support men’s health


So, what can healthcare providers do to encourage men to receive the appropriate care? To start, it’s important for physicians to meet men where they are. Men are less likely to regularly visit a primary care provider, so their first point of entry for medical care may be the emergency room or urgent care center. Emergency physicians often don’t have the chance to address larger issues, but they can encourage men to visit their PCP for follow-ups. Further, 61% of men report they would be more likely to go to their annual checkup if it was more convenient. Physicians can try offering more flexible hours or virtual visits.

Physicians who take the time to communicate with their patients can be an important source of information and support for men who may otherwise avoid talking about their health. An empathetic, direct conversation can help spur men into adopting healthier behaviors or even visiting their doctor more regularly.

Providers screening for mental health issues should also consider how certain conditions may present differently in men and women. Depression often goes undiagnosed in men, in part because they are more likely to report symptoms like irritability, anger, substance abuse or fatigue, which are less-frequently discussed signs of the disorder.

Attitudes about masculinity are changing, and we’re likely to see younger men take better advantage of healthcare services. This is due in part to initiatives like the Movember Foundation, a charity that raises funds for men’s health research and provides resources on mental health, prostate cancer and testicular cancer.

By simply being aware of the statistics showing men may require a little extra coaxing, providers can step in by providing extra incentives for men to visit the doctor. Maybe they offer a discount for partner appointments or maybe they schedule marketing or informational campaigns about recommended screenings where men tend to gather, such as sporting events, golf tournaments or hunting clubs.

As physicians, we have a responsibility to help men understand their health better and eliminate stigmas around getting help. You can’t make them go but you can make it easier.


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Saturday, December 2, 2023

EHR outages and patient safety

On October 4, 2021, the social media platform Facebook and its subsidiaries Instagram and WhatsApp experienced an unprecedented system outage lasting over six hours. While the computer glitch inconvenienced 18 million users and adversely affected small businesses dependent on the technology for sales, it’s doubtful that anyone died. Unfortunately, the same can’t be said when system outages affect healthcare facilities.

For example, a recent lawsuit alleges that a 2019 computer crash at a Mobile, Alabama hospital contributed to the brain injury and subsequent death of a newborn baby. According to reports, when Springhill Medical Center lost access to computer systems due to a ransomware cyber-attack, staff lost functionality of critical monitoring systems including those in the obstetrics department where patient Teiranni Kidd was in labor. The suit alleges that because electronic fetal monitoring systems were down, doctors were unable to diagnose and treat the fetal distress that ultimately led to serious brain injury and later death of the baby.

Responding to the lawsuit, Springhill denied responsibility for the baby’s injuries, pointing the finger instead at Dr. Katelyn Braswell Parnell, the obstetrician on duty. The hospital argued that the doctor chose to deliver the baby despite knowing that the computer systems were down at the facility, and that if she felt it was a risk, she should have transferred the patient.

While the answer to who is ultimately responsible for this outcome will be examined by the legal system, it begs the question of how physicians should handle patient care during a catastrophic system failure. After all, what doctor hasn’t been faced with a waiting room full of patients and a sudden unexpected EHR outage?

When computer systems crash, physicians face a serious dilemma. While administrators scramble to follow ‘downtime’ protocols, handing out paper forms to capture billing and coding and reminding doctors to enter data when systems return, physicians are faced with the question of patient safety and liability. Do we try our best to aid our patients with limited information, hoping that we don’t make a life-threatening error, or do we turn the patient away under the principle of primum non nocere?

According to Tony Quang, MD, JD, who is not involved with the ongoing case, the answer comes down to standard of care. “Ultimately physicians are responsible for the care that they provide. If you can provide standard of care despite your system limitations, then go ahead. But if it breaches standard of care, you need to stop.” If you must continue to provide care during a system outage because of an urgent or emergent clinical situation, Quang advises immediately documenting the situation as soon as the electronic medical record becomes available. “You also want to document the situation in detail as soon as possible to justify your actions. Document that the EHR was down; I had to see the patient and perform said procedure because it was urgent or emergent in nature, and by not intervening at the moment, the patient would have been harmed.”

If caring for the patient would be unsafe without electronic systems in a non-urgent/emergent situation, Quang urges physicians not to accept the risk. “You need to remember that protocols are in place for a reason. Never override or ignore them.” Quang acknowledges that this full stop can be difficult for physicians who are by nature resourceful and used to doing their best with what is available to care for patients—even going so far as try to compensate for system failures and limited resources.

Doctors may also be pressured by their employers to continue ‘business as usual’ despite a lack of medical records critical to ensuring safe patient care.For example, a public statement released by Springhill Medical Center during the cyberattack reassured patients that care was ongoing and would not be compromised during the outage, stating that the hospital, “has continued to safely care for patients and will continue to provide the high quality of service that our patients deserve and expect.”

The decision to continue care without necessary resources outside of the physician’s control can be difficult. Tina Adams, MD, an obstetrician in Jacksonville, FL, says that there are circumstances in which she would be forced to continue to treat patients even in a major systems failure. “As an obstetrician, I’m subject to the Emergency Medical Treatment and Labor Act (EMTALA). I can’t turn laboring patients or those with a medical indication for delivery away. And even if I tried to transfer, the other hospital likely wouldn’t accept the patient.”

While Adams does not have any specific knowledge of the details of the Springhill Medical Center case, she suspects that the obstetrician may have been ‘between a rock and a hard place:’ “If a patient arrives in labor, and I send her away, it’s an EMTALA violation. If the hospital is open and staffed and I have a patient who needs induction for a medical reason and they can normally deliver that patient there, I have no choice but to deliver her because she is my patient, and I don’t have privileges elsewhere.”

Regarding the hospital’s responsibility, Adams notes that when electronic fetal monitoring systems are down, labor and delivery floors usually shift to a 1:1 nursing model for laboring patients in which obstetric nurses stay at a patient’s bedside to continuously watch the tracing for signs of fetal distress. “If the hospital didn’t think it was safe to function, they should have closed the unit.”

Physicians must realize that they are likely to be held responsible for bad outcomes that occur during system failures, even if they are urged to continue to provide care by their employers. “If you think something is unsafe, don’t ever do it,” advises Tony Quang MD, JD.“While this decision may appear to conflict with employers’ wishes, it may prove to be a win-win for all—the patient, who does not want to be harmed, the physician, who does not want to cause harm, and the employer who wants to avoid legal action against them.”Quang notes that exceptions may be necessary in emergency situations and suggests that physicians who face this circumstance immediately activate the chain of command and document their decision-making carefully.

With an increased dependence on electronic systems in healthcare, physicians are likely to face unexpected outages—after all, even giants like Facebook can’t keep things running all the time.We must be prepared to evaluate the situation to determine whether standard of care is possible. If not, we must not compromise patient safety. Above all, do no harm.


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