6 top medical comments, April 19th 2009

Here are some of the more interesting comments readers have left recently.

1. Manalive on quality measures:
It is almost always a leap of faith to apply evidence-based guidelines to the frail elderly, to patients with many medical problems, to alcoholics, to the poorly insured — in short, to a large percentage of my practice. Accordingly, I have been on the wrong end of too many evidenced-based beatings for my liking.

A few years ago I realized that my bonus, based on my “quality” management of diabetes, was compromised by the poor quality of my patients. I then dismissed many of the alcoholics and non-compliant (more correctly, I maneuvered them to dismiss me — much less hassle); and my bonus scores have greatly improved.

2. Stitched_Up on the nursing shortage:
It’s quite true that the shortage is being masked by hospitals trying to make the most of the staff they have and NOT hiring.

Many hospitals are currently playing the “float pool” game. By eliminating overtime and hiring more per diem staff, they can have full time equivalents that cost the hospital a few dollars an hour less than a nurse with full benefits.

The real COST however is the lack of stability that the “nurse in the field” feels when they have to rely more and more on people that simply “float” into their departments.

3. Eric on whether jet lag needs a cure:
Not everyone has the luxury of being able to pad travel schedules with acclimation days; as someone who has had grievous cognitive lapses due to disrupted sleep schedules when traveling, I welcome this indication. The $8 for a Provigil/Nuvigil tablet is a fraction of the damage I can cause if I’m off my game and trying to think through that fog. Yes, proper sleep hygiene, less-punishing travel schedules, teleconferences and other techniques can improve jet lag function, but when you’re moving through 12 time zones in a week, you’re a mess.

4. Dr. Ike on paying doctors by the hour:
My feeling is that any time you can provide a doctor security/peace of mind, the quality of patient care will rise. Whether he or she is seeing five or fifty patients in a day, one less worry is one more focused thought on the person needing treatment.

5. Xanontl on whether a DNA test can replace the Pap smear:
Kevin, thanks for pointing to this important study. [You’re welcome -k] Unfortunately, you failed to mention that it was specific to resource poor settings that are unable to do pap smears.

There are other studies from Canada and Sweden that point to the effectiveness of the HPV DNA test, but not as a replacement for pap tests entirely. It’s also more helpful for women over 30. Women under 30 often clear HPV infection, and a Pap is a more reliable assessment of cervical health.

6. Matthew Mintz on stimulus money and health IT:
Once again Kevin, you are completely correct. [Why, thank you -k] But also don’t forget that most health care occurs outside the hospital. The problem of EMR’s not being able to talk to each other goes far beyond one hospital to another. If all physicians are expected to use an EMR, then the primary care doc’s EMR should talk to the hospital and vice versa, the primary care doc’s EMR should talk to the specialist’s EMR and vice versa. The outside (non-hospital) lab, radiology center, etc. need to talk to all the doctor’s offices and the hospitals.

If we are to save any money by investing in health care IT (which I don’t think will happen, though I am in still in favor of invesitng in health care IT because it will improve quality), then intraoperability is the critical factor. The problem is that all the money is going to the hospitals to improve systems that they likely already have. It would be better (in my opinion) to spend the money on creating one good system that actually works well and then let everyone have it.


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