by Vadim Shteyler
Amid this week’s disheartening studies highlighting discrimination of LGBT populations, the American College of Physicians (ACP) affirms its support and offers new recommendations for furthering LGBT health.
The bad “news”: is not really news. It is further evidence of how much more effort needs to be placed on ending LGBT discrimination and inequalities. A national survey published in the Ann of Intern Med found that lesbians were significantly less likely to get vaccinated for HPV than their heterosexual counterparts (adjusted prevalence of 8.5% v 28.4%). HPV is easily transmissible through contact and believed to be equally transmissible in gay and heterosexual women. The vaccine can prevent most cases of cervical cancer, which has terrible outcomes if discovered late, indicating that many deaths could have been prevented. An editorial in the same issue describes neglected health concerns affecting LGBT populations and calls for better professional education on LGBT health. The CDC’s and American Congress of Obstetrics and Gynecology’s (ACOG) efforts to inform patients about pap smear rates not been slow and inconsistent in changing medical practice. Combined with markedly lower HPV vaccination rates, cervical cancer remains a big concern. Continue reading
by Vadim Shteyler
Efforts to improve health care quality under the ACA have been directed towards expanding EHR use and health IT, improving care delivery by promoting care coordination and population health, and laying incentives for providers to meet quality measures. The 33 ACO quality measures include 8 measures to evaluate preventive care, 12 measures to address goals of managing 4 common diseases, and 7 to assess patient satisfaction. Though quality improvements have not been consistently shown, studies have found modest Medicare spending reductions. In fiscal year 2013, CMS began reducing health care reimbursement rates to hospitals with excessive 30-day readmission rates, as generalized by their readmission rates for heart attacks, heart failure, and pneumonias. These were extended to include readmission rates for hip and knee surgeries in fiscal year 2015. And, as readmissions were estimated to account for $17.5 billion of Medicare costs in 2012 (in part attributable to insufficient discharge services, access to outpatient care, and follow-up), efforts to curb them are expected to continue.
The ACO quality measures have been criticized for being too process oriented (as opposed to outcomes oriented). And, undoubtedly, so few quality measures can’t encapsulate all of health care. Noted shortcomings of readmission rates as a valid indicator of quality include that they do not differentiate between planned and unplanned readmissions and they don’t adequately control for different case-mixes between hospitals. As psychiatric illness is often poorly recorded in medical records, it is a major confounder that may impact different hospitals differently. In this blog post, I add the speculative concerns of a medical student from limited experiences on the wards. Continue reading
by Vadim Shteyler
A.F. was an elderly patient admitted to our service for a diagnostic work-up and management of a large pocket of pus surrounding her lungs. Until recently, she was very independent and in good health; this was her third hospitalization for the same reason in one month. Radiographic imaging was consistent with pneumonia but other causes could not be ruled out. She had not responded to antibiotics, she had no other signs of infection, and numerous cultures from her blood, pus, and sputum failed to grow microbes. Extensive testing for other possible causes was also negative. At that point, we all had the same suspicion—cancer. Some tumors in the chest can cause inflammation that may look like a pneumonia and result in a collection of pus. That inflammation can also hide the tumor on imaging. In fact, it would be a few weeks, after we drained all of the pus and the inflammation subsided, until we would have a clearer image of the lungs. Though cancer was a plausible explanation, we had no evidence at that time. Should we have discussed our concerns with A.F.? The diagnosis was not certain, so we didn’t…
In daily clinical practice, uncertainties come in many forms. Outcomes for most medical interventions are probabilistic (they are not 100% predictable). And those probabilities are often ambiguous (they are more often ranges than specific percentages) or simply unknown. At a broader level, science is underdetermined, medicine is inductive, and innumerable non-medical forces influence the medical landscape (biases, conflicts of interest, values, etc.).
How effectively providers communicate uncertainty is…well, uncertain. Continue reading
by Vadim Shteyler
As a medical student on the wards, physicians often recounted stories of horrifying acts of paternalism from the days of their training. Though paternalism is far from abolished, the progress we have made as a profession has become a source of some pride. On the wards, autonomy has become exalted as a sacred right and invoking paternalism can end most debates. Though autonomy is a complicated and frequently debated concept, most agree that the cultural shift is a step in the right direction. And though perhaps we should be proud of our steps towards protecting the way patients receive information in clinic, we should be more aware of other sources of patient information as well.
Of course, it may not come as a surprise that a lot of the medical information available to patients is less than accurate. With the Internet, ubiquitous misinformation about anything should be expected. However, when we think about the sources of that misinformation we often think about random websites found during quick Google searches, Wikipedia, sensationalized media coverage, and pharmaceutical advertisements (the later will be discussed further below). A few recent studies are bringing attention to more surprising culprits: Hospitals and Academic Institutions. Continue reading
by Vadim Shteyler
The growing accessibility of Electronic Health Records (EHRs) across hospitals and practitioners raises new concerns about patient privacy. Before EHRs, patients had control over how much information they shared with each healthcare provider. Receiving patient information from other practitioners has required a signed consent form specifying the information patients are comfortable sharing (e.g., radiological studies, mental health history, sexual history, etc.). And hospitalists have been expected to request the minimal necessary information to provide good care. With growing networks and increasing compatibility across EHRs, more providers now have access to information without the patients’ express permission or even awareness.
Recent works published in the Journal of General Internal Medicine reported the results of a study that designed and recorded patient and provider experiences with a patient-controlled EHR (in which patients chose which providers could access which data in their medical records). A preliminary survey showed that, before the study, only 10 percent of patients had access to their medical records. Half of surveyed patients did not know what information their EHR contained. However, all patients wanted access to their EHRs. Meanwhile, another study reported that only one-third of physicians thought patients should have EHR access. Continue reading
by Vadim Shteyler
On the wards, resident duty hour restrictions were a frequently recurring topic of heated discussion. Effective July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new limitations on resident work hours for all ACGME-accredited residency training programs, furthering the existing limitations from 2003 reform. Current policies restrict workweeks to 80 hours. Residents must get at least four days off every four weeks. Shifts are reduced from 30 consecutive hours to 16 consecutive hours for first-year residents and to 24 hours for all other residents. First-year interns must have eight hours off between shifts. And residents after 24-hour call must have at least 14 hours off.
Proponents argue that exhaustion contributes to medical errors, such as the death of Libby Zion (whose tragedy prompted the conversations and the policies limiting duty hours). Longer hours can lead to poorer quality of life, ultimately harming patient care. And inefficiencies in the more frequent handoffs are reasons to focus attention on handoffs rather than lengthen shifts.
Opponents have an unlikely ally, many residents and physicians. During my rotations, many argued that fewer hours on the wards translates to less real-life patient exposure and under-preparedness for independent practice. Continue reading
By Vadim Shteyler
Increasing hospitality in medical facilities is not a recent trend. We take for granted that modern hospitals offer clean sheets, towels, a plethora of toiletries, heated blankets, and many other amenities. Conversely, in the hospitals of decades past, many patients relied on family members to bring food and clean sheets. Rows of hospital beds in an open ward precluded privacy. Unhygienic conditions commonly resulted in rodent infestations. And paternalism in medicine was still the norm.
This trend towards hospitality has recently gained new momentum. As featured in a recent article in Kaiser Health News, dozens of hospitals have hired Chief Patient Experience Officers from customer service or hotel industries. Since 2012, when Medicare began penalizing hospitals for poor patient experiences, hospital efforts to improve patient satisfaction have grown. Some hospitals began mandating communication seminars, encouraging nurses to spend more face-to-face time with patients, and calling patients after discharge to follow-up on their recovery. The Affordable Care Act (ACA), further tying hospital reimbursements to patient surveys, has additionally promoted such changes.
A similar trend has arisen with the increased popularity of V.I.P. sections in many hospitals. Though the hospital construction boom is beginning to slow down, the resultant V.I.P. rooms remain. Lenox-Hill Hospital’s maternity suite in New York City, which received a lot of media attention after Beyonce gave birth there in 2012, is one of many luxurious suites across the nation. Some, offering personal shoppers, private chefs, and salon services, are priced upwards of $4,000. While nobody calls for a return to the hospitals of old, many feel suites such as these are excessive. Continue reading
by Vadim Shteyler
Interdisciplinary collaboration between all healthcare professionals involved in an individual patient’s care has been increasingly recognized as vital for providing high quality medical care. However, when it comes to hospital management, decisions affecting daily workflow are still largely made by physicians.
The movement towards an inter-professional team approach of providing medical care is still new but gaining widespread support. To characterize the disconnect between the presence of inter-professional collaboration in medical care, but its absence in healthcare management, it is valuable to understand the rationale for inter-professional teams in healthcare. Continue reading
By Vadim Shteyler
In a previous blog post, I introduced Dutee Chand, a world-class sprinter suspended from national and international competitions by the International Olympic Committee (IOC) and the International Association of Athletics Federations (IAAF). According to the policies of these organizations, an athlete with testosterone levels in the male range cannot compete in the female category. As I discuss in my previous post, by creating a definition of sex that is meant to only be applicable in sports, the IOC and IAAF effectively created a situational definition of sex.
Sex is poorly defined.
From the debate that arose after Dutee Chand’s suspension—as well as from other recent controversies surrounding sex-segregation in bathrooms, prisons, the military, and many other settings—it is evident that people cannot agree on a definition of sex. In the United States, sex is defined differently in different contexts. At birth, it is defined by external genitalia. In genetic testing, it is defined by chromosomal makeup. In everyday life situations, it is defined by clothes, hair, and other select physical features. Continue reading
by Vadim Shteyler
Dutee Chand’s career was rising quickly—in 2012 she was the Under-18 Indian National Champion for the 100-meter race. In 2013, she became National Champion in the 100 and 200-meter races as well as the first Indian to reach the final at the World Youth Championships. However, on July 15, 2014, her career was placed abruptly on hold when she was banned from all national and international competitions as a female competitor. Testing revealed that she had hyperandrogenism, that is her body naturally produced elevated levels of the male hormone, testosterone.
In April 2011, the International Olympic Committee (IOC) and the International Association of Athletics Federations (IAAF) had instituted policies banning all athletes with testosterone levels at or above the lower limit for males from competing in the female category. The policy allows women to requalify if they are shown to be resistant to the effects of testosterone or if they undergo one of a number of medical interventions to decrease their testosterone levels. This policy was a change from the extensive medical and psychological testing used for sex verification. (Read more about Caster Semenya, whose experiences catalyzed the policy change.)
Supporters of the new policy argued that a male competing among females has unfair advantage and, as such, furthers his career undeservingly and wins medals for his country unjustly. If increased testosterone levels largely contribute to the better athletic performance of males, then athletes with male-range testosterone should be banned from female competitions. Further, the IAAF cutoff for female testosterone levels is greater than 10 times the mean for average women, ensuring that the vast majority of women, even those with elevated testosterone, would not be disqualified based on these criteria. (Read more in The Journal of Sex Research.) Continue reading