Patient Satisfaction. What happened to, "First, do no harm?"


Remember this study from 2012?  

The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality.


The conclusion:  "In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality."

Yet we continue to use patient satisfaction scores.

What happened to, Primum non nocere? First, do no harm. 

During B-school, I learned that what gets measured, gets done.  But what if the thing we are measuring is causing harm to our patients?

I get it though. I love to see happy patients who say, "Thank you!" It makes me feel good about my career. 

But I don't what that measured, especially if it's causing harm! 

If doctors are paid to please patients, how does an MD tell his patient to lose weight, quit smoking, eat right, and that antibiotics are unnecessary for their URI?

The solution is simple. 

D/C patient satisfaction scores. 

Ketamine instead of 5150?

I frequently see patients who are depressed and suicidal. It's tough for our patients and I wonder what can be done for them.

My typical plan of action is to medically screen these patients, including: history, physical exam, labs, urine toxicology screen, and call for a psychiatry consult, if available.

Usually, these patients wait for a long time to be transferred to a psychiatric medical center where they can be evaluated by a psychiatrist.

Now, studies have shown that giving a low-dose ketamine (0.5mg/kg) intravenous push can rapidly alleviate these symptoms. 

http://www.ncbi.nlm.nih.gov/m/pubmed/23982301/

http://mobile.nytimes.com/2014/12/10/business/special-k-a-hallucinogen-raises-hopes-and-concerns-as-a-treatment-for-depression.html?referrer=&_r=0

Would it be more beneficial for some patients to be treated with ketamine in the ED with outpatient psychiatry followup? 

This would enhance medical care in several ways:

1. No waiting in ED for psych bed
2. Rapid alleviation of depression symptoms
3. Return to home sooner for patients

The next step is to do randomized controlled studies in ED patients who present with suicidal ideation and see if they benefit from a dose of ketamine.

Starting to Get it Right

“The moment that you feel that, just possibly, you’re walking down the street naked, exposing too much of your heart and your mind and what exists on the inside, showing too much of yourself. That’s the moment you may be starting to get it right.”
- Neil Gaiman
“Neil Gaiman Addresses the University of the Arts Class of 2012” by The University of the Arts (Phl) on Vimeo.  http://vimeo.com/42372767

Starting to Get it Right

“The moment that you feel that, just possibly, you’re walking down the street naked, exposing too much of your heart and your mind and what exists on the inside, showing too much of yourself. That’s the moment you may be starting to get it right.”
- Neil Gaiman
“Neil Gaiman Addresses the University of the Arts Class of 2012” by The University of the Arts (Phl) on Vimeo.  http://vimeo.com/42372767

3 Reasons To Change Medical School to 3 Years



1.  The majority of learning happens in the first 3 years.  The fourth year of medical school is devoted for electives and interview season.  Once interview season is completed, there's plenty of downtime. Accordingly, the fourth year should be eliminated completely.  Or it can be offered as an option for those who don't know what specialty they have decided upon.  Students don't need to be in school for interviews and could spend extra time recuperating for internship or working part-time to pay off loans.

2. There is a shortage of doctors.  We can increase the number of graduating MDs each year and accordingly address the MD shortage that affects our society.  "The Association of American Medical Colleges predicts bigger shortages in all types of physicians: 63,000 by 2015 and 130,600 by 2025. This means more doctors to help meet the needs of underserved areas, entering primary care, and more MDs doing research.

3. Doctors already have too much debt.  In 2012, the average graduating MD starts out with $170,000 of student loans.  If medical school were reduced by one year, it could reduce educational debt by up to $50K.  Additionally, there is the opportunity cost to consider of this extra year.

So how can we make it three years?  All schools should offer the option of an accelerated curriculum for interested students.  Medical students will be graded upon clinical competency and test scores. If they are incompetent or failing, then they simply don't graduate.

Day-In, Day-out Practice of Medicine


It’s the humdrum, day-in, day-out, everyday work that is the real satisfaction of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of weekdays and Sundays that make up his life.  I have never had a money practice; it would be impossible for me.   But the actual calling on people, at all times and under all conditions, the coming of grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me.  – William Carlos Williams