Cast & Curious

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  • Serving communities near one’s previous home…

    Two days ago I had this rare chance of visiting a community hospital near my birth place. I went to this “far flung” community to see patients admitted at an 18 bed primary  hospital, the only one within in a 20km radius in that area. Many had reservations going to this place. A few doctors were brave enough to serve this community despite constant threat of being abducted or god knows what.

    Anyhow this community is significant to me because of its proximity to where I was born and where my family previously lived. Just about a few kilometers from our previous, memorable home. My parents both worked at a big corporation previously operating north of this community. Both migrants to this place, this is where they met and fell in love with each. Three of my siblings were born here. I was born here. I grew most of my formative years in this relatively serene and laid back far flung community. My family built memories here. When my dad passed away and the company pulled out of the community because of the worsening peace and order, we left the place too and settled here in our present area. Since then I never had a chance of  coming back to this community, to even gaze at my birthplace, to even walk at the staircase of our former house, or maybe swim again at the duck pool, or climb that santol (tamarind) tree.

    Such a relaxing sight don't you think? (photo credits here)

    On our way to this community hospital, I rekindled familiarity with the road, of the lush green rice paddies alongside, those white herons on water buffaloes’ back, and that smiling townsfolk half submerged in mud paddies trying to catch some catfish. I saw all of them again and for a moment I am happy.  I wanted to take out my camera and take photos but I hesitated wanting to enjoy the moment rather than fiddle with a gadget. So close to home. So close.

    At the hospital I examined patients at the same time exchanged jokes and stories with some of them. I used to understand and speak their language but now, I can only understand common phrases and blabber “yes” and “no” in their dialect. One patient even joked “our doctor now is kind of a joker” in their dialect to which everyone in the ward was laughing.  Strange, but I felt a strong feeling of commonality with them.

    I went there as a physician more than an orthopedic specialist and I saw diseases that were epidemic in far flung communities – water and food borne disease as well as animal transmitted diseases. It reminded me of my community internship in one far flung province somewhere north. But this is close to home and admittingly, close to my heart. Many would find me reckless and bold to go there despite the risks, and even I was surprised It turned out to be a pleasant and heart warming visit, but some things are never meant to be understood or left to calculating risks. I cannot answer why I did it. I just felt doing it.

    Will I do it again? Who knows. Maybe in another opportune time. When I could go even closer to home…

  • Do we need a law that protect healthcare providers if they disclose or confess medical errors?

    Central to correcting medical errors is accepting one first, if it did happen. Improvement in healthcare delivery will only happen if we learn from our mistakes and make concrete, active steps to rectify it. This is what we actually do during mortality and morbidity conference- analyze medical events and cases to help improve delivery of healthcare services.

    The health care industry accepted the occurrence of medical errors decades ago. But disclosing medical errors publicly is unpopular even in countries where litigation is relatively not so common. Why? No one really knows. In our society however, publicly apologizing for one’s true medical mistakes is akin to killing your medical career. I guess it’s a bit easier to admit moral turpitude publicly than let’s say admitting you misdiagnosed a patient. The acceptance is just too low.

    But what can we do? First, we should create an environment of open-mindedness among medical peers and enact laws that will protect disclosures of medical errors publicly. That way, we can freely examine medical errors to institute appropriate corrective actions based on acceptable and evidenced based medical practice.

    This is what John Hopkins University Hospital is doing since 2001. Their  Disclosure Policy  protects and actually encourages employees to confess or report medical errors. This is partly the reason why JHUH  litigations have continually decreased ever since the policy has been implemented.  John Hopkins is the top ranked hospital in the US for 20 years already.

    Medical errors simply don’t surface over time. For us, providing a “medical whistle blower” law might just be the first step in improving delivery of healthcare services. Don’t you think so?

     

  • Loyal patient watchers..

    Communication, patient-provider (photo taken from http://www.aafp.org/fpm/1999/0500/p23.html )

    I was doing my usual morning rounds last tuesday when a watcher of one of my patients approached me before I saw their patient in his bed. This watcher mentioned that someone went inside their patient’s room and asked questions that raised the curiosity of the family. The watcher spoke a different dialect and though I understood most of what she’s trying to convey, she fumbled with words and was obviously concerned at the “questioning” incident. I asked about the details of the incident, but none of them can give me a clear idea what was the “questioning” all about.. All I can deduce from the watchers was that someone asked them and “implied” a question of competency  and thus are worried about their decisions in seeking my care.

    Unfortunately, none of the watchers asked (they are probably too shy or too gentle) the name nor remembered the identity of the person. They describe the interviewer as wearing a white dress and was asking other questions like “Why go to this hospital?” or “Who told you or referred you to this institution?”.

    I asked the family then if this did affect their perception of my competency. I heard a resounding “Hindi po” or “No, it didn’t”.

    I suddenly remembered who the interviewer could be. None of these watchers realized  that the interviewer was actually  doing a sanctioned survey.  I have yet to encounter this response variance (meaning, the watcher doubted competency as a result of being interviewed) in any surveys I’ve been involved. This however pointed out one thing- a communication gap between the interviewer and the interviewee. The interviewer broke protocols by not introducing herself (blinding?) which rose suspicion and doubts on the part of the interviewee. Imagine what a simple mistake like this evoking a different response!

    I  felt relieved discovering this fact but was bothered by the communication gap. I spent more time explaining the survey and placate these watchers apprehensions. This time spent explaining will go a long way protecting a provider’s image from a simple neglect of introducing oneself before any patient or watcher’s interaction.

    So doubts? Nah. But I’m sure that staff will have something to learn from communications 101!

  • Challenge and fun of developing a clinical pathway

    When evidence based medicine (EBM) came to the halls of PGH  during my residency training, I was one of those few who “liked” its surge because of its “collaborative” approach and  ‘standardizing” effect on treatment protocols for a specific disease.  So honing my skills on study appraisals was a consequential habit I gained even into my private practice.

    Cartoon of Cpath taken from Medscape. Uphill challenge.

    But as a surgeon physician, I hated paper works. EBM entails lots of reading, studying and sifting through researches and thus, paper work. I’ve always hated the voluminous paper works that goes with caring for your patients. As I go through to my private practice, I began scrutinizing my clinical practice looking out for ways ( aside from and in addition to EBM) to standardized treatment and save on unnecessary stuff, like paper work, time and cost , without sacrificing quality of care.

    Enter clinical pathways. I first heard clinical pathways development in one of our specialty meeting, when Philhealth (Philippine Health Insurance Corporation), Philippines  largest and government owned HMO, mandated Philippine Medical Association (PMA) and its components society to come up with clinical practice guidelines and clinical pathways for diseases specific to sub specialties. I only have faint ideas about clinical pathways back then but I surely know its one process you get from CPGs itself. They’re siblings I guess.

    [pullquote]Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).-wikipedia[/pullquote]

    So when Philhealth came to our hospital for inspection, I only offered our CPaths when they asked for our clinical pathways. I was asking  the physician evaluator what clinical pathways and if we don’t have the data yet, how are we going to go about it, they too have a few ideas. It was a new thing here in the Philippines and even us, don’t know where to learne this stuff.

    The good thing is, the Philippine Society for Quality in Healthcare (PSQUA) held a workshop on clinical pathways and I was one lucky sent to attend such training. I’ve certainly learned from that workshop, and it’s such gratifying to know we’re abreast with the current trends and are developing our own pathways fit for our local socio-cultural, economic healthcare situation.

    Last week, I was able to give back a workshop on Clinical Pathways development to our very own hospital staff. Most of them are allied medical professionals who are our partners in the care of our patients. One doctor. Never the less, imparting learned skills is always an important thing in any collaborative effort, especially in caring for our patients. The great misnomer about clinical pathways is that it’s not all about doctors and collaborating with other specialties. In fact, it was more of collaborating with the different health care professionals ( nurses, pharmacist, dietitian, etc ) that help us care for our patients. That’s is what developing a clinical pathway is all about.

    SLH Staff on workshop for CPath Development

    Well, it’s not important that I like statistics, and I enjoy teaching. Imparting knowledge is one hell of a gratifying activity I would pick at, anytime!

  • Should new technologies in medicine threaten one’s (old) practice?

    In one community where I practice, no hospitals offered diagnostic procedures like CT Scans or MRI (Magnetic Resonance Imaging). Thus the current practice is to immediately transfer the patient to a nearby hospital with such capabilities. This, in spite of the fact that medical professionals here can actually perform the needed medical procedure after the CT was done. This practice went on for so long as I can remember and physicians bothered less and less about honing their skills managing ill patients diagnosed with the help of  a CT Scan.

    Until one day, one hospital invested in a cat scan. Many physicians suddenly find themselves in a dilemma. That despite, the availability of a ct scan now, many physicians lacked or simply forgot to learn or re-learn how to manage patients that was diagnosed with the help of a CT scan.

    Many physicians view new medical technologies as a threat, simply because they lose patients in the process.  Somehow though, there’s this lukewarm acceptance for re-learning of skills. The quandary is not about what you don’t know, but about how confident are you in managing those that you now knew because there’s a CT. Should they still refer the patient to another city for treatment despite the fact that the diagnostic technology is available here already? Would you see this as an opportunity for re-learning or would you simply refer the patient and free yourself the hassle of it?

    This is just an example of technologies that threaten conventional practice. Many physicians view it as a threat, simply because they lose patients in the process but somehow, there’s this lukewarm acceptance for re-learning of skills. For some, this an opportune moment for seizing the timing for creating value added services (like ICUs and neurosurgery) in the hospital. For patients, this is totally a welcome development and improvement. Lower costs and convenience for both the diagnostic procedure and the value added service cannot be simply ignored. New technology, if indeed necessary, is here to stay.

    So are you going to just ignore it and go on with your old practice or re-learn skills to adequately manage the influx of patients as a result of new technologies? Put your comment below.