Wednesday, January 30, 2013

Doctors Die Differently

It was this podcast, "The Bitter End"

From the awesome radio show radiolab that covered a topic that people are often reluctant to discuss but is an important part of our they say there are few things in life but birth death (and taxes) are at the top of the list.

The piece included a review from the Johns Hopkins (Study of a LifeTime) of people's desires when it comes to life saving treatments especially as it relates to end of life:

Preferences of physician-participants for treatment given a scenario of irreversible brain injury without terminal illness. Percentage of physicians shown on the vertical axis. For cardiopulmonary resuscitation (CPR), surgery, and invasive diagnostic testing, no choice for a trial of treatment was given. Data from the Johns Hopkins Precursors Study, 1998. Courtesy of Joseph Gallo, "Life-Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?"

For some simple questions such as:

  • Would you want CPR administered
  • Would you want Artifical Ventilation administered
  • Would you want Dialysis administered
  • Would you want a Feeding Tube used

Physicians were fairly uniform with 80% declining all of the above therapies. The only question that physicians were uniformly in favor of was the administration of pain medication.

But ask the same question of the general public and the numbers are reversed on every therapy (except pain management where there is agreement)

Its not that doctors don't want to die, its just that they knwo they know enough about modern medicine to know its limits, importantly they have talked about this with their families as they want to be sure that no heroic measures will be used during their last moments in this reality.

In this excellent piece: "How Doctors Die; It’s Not Like the Rest of Us, But It Should Be" Ken Murray elegantly discusses this discrepancy

The challenge is clear and effective communication on a topic that we are reluctant to take on:

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

My personal technique when I was practicing was to use the benchmark of my own family. Depending on the age fo the patient I would ask myself the questions:

What would I do if this was my <insert name of close family relative>


What would I do if this was my son/daughter
What would I do if this was my spouse
What would I do if this was my mother/father/brother/sister
What would I do if this was my grandfather/grandmother

It may seem simple but it worked for me, and still does. The principle applies with general discussions between family members and realtives.

I knwo this seems morose and depressing but remember death is not alwasy the worst case scenario.

Posted via email from drnic's posterous

Wednesday, January 23, 2013

Yoda's 1st Law Of Health Quality And Performance Improvement

Great post on the challenges around pay for performance that highlights an interesting fact - Bill Clinton's heart surgeon Dr Craig Smith has some relatively poor outcome measures...not because he has bad outcomes but because his practice takes some of the most high risk patients.
It is hard to take account of these numbers in the performance metrics.

So the next time you see performance or quality criteria - take a step back and dig deeper into the number

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Friday, January 18, 2013

Restyling the Mundane Medical Record Could Improve Health Care


Too good to not follow up to the previous post as another great article on re-workign the medical record (perhaps medical "record" is not a great term?). Personal Health Story/Personal Health History/Personal Health Chronicle...
Whatever we call it this will be is the way our health information will be stored and shared

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The Future of Medical Records - Great Outline of Possible Future


Nice post on the possible future of medical records - there has been a lot fo traffic on my e-mail on the lack of value of EMR's and several folks commented on the lack of innovation in the systems. Several noted that just digitizing the paper process will unlikely bring any satisfaction or even major progress to Healthcare
Which is why this piece is so timely - some great concepts, visually pleasing and offering some interesting ideas

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Monday, January 14, 2013

Intensive Care Information retrieval system

Intensive Care Information retrieval system from our friends down under showing the value of Natural Language Processing to get into the detail of clinical notes, understanding the underlying content. The demo shows the ability to get to information even when there have been typographical errors or use of abbreviations that either have multiple meanings or are not approved/recommended for use.
This technology is now being applied at the point fo clinical data capture ot correct these errors and others and clarify the clinical documentation prior to commitment to the clinical database and Electronic Health Record

Posted via email from drnic's posterous