Cast & Curious

Tag: healthcare

  • 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 health care professionals in developing countries have a social media presence?

    The short answer is yes, they  should. Consider this:

    The Philippines, a developing country, is the social networking capital of the world. It tops the list of nations who uses Facebook. Or before Facebook, Philippines also topped the list of nations using Friendster.

    1. Philippines
    > Facebook: 93.9%
    > Twitter: 16.1%
    > LinkedIn: 1.9%
    > Internet Use: 29.7%

    Social network penetration is incredibly high in the Philippines, reaching 95%.  Facebook is the country’s most popular website, more so than Google, and has a penetration rate of 93.9%.  The Philippines is also the eighth most popular country for Twitter use on a global scale, with a penetration rate of 16.1%.  The popularity of photo sharing has increased by 46% in the country in one year, largely due to Facebook.  Social networking is so popular among Filipinos, the country has been nicknamed “The Social Networking Capital of the World.” –The Ten Nations Where Facebook Rules the Internet | 24/7 Wall Street

    Infographic from this site ( http://internacionalmagazine.com/2011/03/comscore-has-crowned-philippines-as-the-world%E2%80%99s-heaviest-users-of-facebook/1490/

    Also, most of the other nations in the list are developing countries in Latin America and South East Asia. These  social media platforms are good mediums for health education and should augment health drives using traditional media.

    Medical information through the internet is readily available and fast. Most of informed patients nowadays get their medical information through the internet. Also, most of this informed patients (or their relatives, guardians etc.) also maintain a social media presence in facebook, twitter or in a blog. The multiplier effect of posting it on your facebook profile is just way beyond that can be achieve by traditonal means, like books.

    Interactivity is fast, patient questions can be addressed rapidly and doubts can be clarified and , it is a good jumping off for a “real” clinic consult. The potential for  improving physician-patient relationship and interactions using social media is enormous. Not taking on this opportunity simply deprive the already shortchanged health education in developing nations.

    Is this enough reason for you to act now and have your social media presence be felt?

  • When surgeon shopping ends up with just facility shopping…

    “Hello! And again!” I happily greeted this patient sitting on my clinic chair. He smiled back , albeit sheepishly and said  “Sorry doc!” . “Don’t mention it, it is your right by the way”.

    (Photo credits goes to http://blog.drfirst.com/eprescribing/florida-providers-beware-of-doctor-shoppers/)

    I saw this patient about 2 months prior to this consult in one of my other clinic in another institution. He consulted me for a certain orthopedic problem, examined him, ordered the needed diagnostic procedures and appraised him carefully of my treatment recommendations. This including financial considerations and proximity of institutions where we can do the necessary procedures. Then I lost him to follow up.

    Mr. X resurfaced 2 weeks after, in my other clinic,  in another institution thinking he was seeing another surgeon. He was surprised as I am that we met for the second time in another clinic and in another institution.  I don’t know if he was just plainly uninformed or he wasn’t very particular physician names, but I’m pretty sure my name was clearly printed on this clinic door. The guy was surgeon shopping and is surprised that so far, he window shopped the same surgeon in two different institution  – me and myself.

    That aside, I went on with my routine patient consult gave the same treatment recommendations as before. His surgical problems needed the same surgical treatment. Nothing changed. Went he stepped out of my clinic door, I had this inkling I won’t be seeing this patient again. Indeed, I lost him to follow up. Again!

    Until this very moment, when he showed up (again) in one of my other clinic in another institution different from his previous consults with me. I greeted him “Hello, …again!” …He went pale. So the rest of the story goes.

    Just how he ‘window shopped for the same surgeon, three times, without him knowing” is mind boggling. But he obviously wasn’t very particular with names. He was shopping for the “surgeon” who will give him the treatment he liked.  It’s unfortunate he ended up with the same specialist three times, in the process.

    In a small city where “specialists” is as scarce as physician, “surgeon-shopping” may just be actually “healthcare facility shopping’. So patients, pay particular attention to your physicians names…

     

  • Do you charge professional fees for additional procedures done to address complications or morbidity?

    This question was thrown on me recently by a newbie colleague who was agonizing on whether or not to charge patients for an additional procedure he did to address a complication. I instantly went blank thinking what to say.

    when surgery goes wrong…will you charge mr. bean?

    In the field of medicine or at least here in the Philippines, there’s really no hard and fast rules on charging professional fees for services rendered to patients. This service for fee setup of our healthcare system is somewhat messy and often embarrassing to patients and doctors alike. The price haggling is totally unnerving. Sadly, this is what plague the professional practice of most physicians here in the Philippines.

    Such charging “grey” is even more embarrassing in cases where patients entailed additional services outside of their routine or planned operative procedure. While explaining and appraising procedure risks and complications to patients is a requisite of any informed consent, most patients still think that additional procedures,  should be an additional work for the physician and the healthcare providers alone. Patients or their financiers are not obliged to pay the healthcare providers for the services rendered for these additional procedures. Wherever, that notion came from, the stress on the attending physician(aside from that of managing the complication) is enormous, working on a very limited logistics to address complications. Besides, Docs have mouths to feed too.

    This situation is akin to the “heroic” services rendered by physicians to dying patients. Just because the patient dies (despite the doctors valiant efforts to revive the patient), the fees for the physician’s services (resuscitation)  does not “die” with the patient too. Services rendered have to be paid even if the service given did not achieve its original goal (that of reviving the patient). Can this situation be applied to procedures done to address morbidities?

    What do you think??

  • Lesser Surgeons?

    I’m amazed at how surgeons in provinces surpass the seemingly insurmountable odds besetting their practice. I’ve heard of horrifying stories regarding provincial practice during my training, that I sometimes wince at the thought that me too shall join their ranks soon when I get back to my hometown.  Then I got the first hand “feel” of what its to be like a surgeon from the provinces.

    In my first year of practice I remember managing one patient who sustained multiple closed fractures of the ankle and that of the leg. On treatment appraisal I found out the guy can afford an operative procedure for the (bimalleolar) ankle fracture but not that of the leg fracture. I was in a dilemma at that time since current evidence only supports good overall functional results if both fractures will be treated operatively at the same time. Treating the two fractures differently or separately will result to a less than good outcome the review further noted. I racked my brains out for a middle ground solution. I can find none more than speculative statistics. I presented this dilemma to the patient and let him decide based on the ‘literature” and statistics I was explaining. I was dumbfounded with what he told me after my lengthy explanation. “Do what you think is best doc”.

    Not only that.  I  told the patient that because we don’t have intra-op x-rays in that institution, it’s either we risk infection bringing out the patient to the x-ray room during operation to check for fracture reduction or just feel out reduction and accept whatever comes out after surgery. His only answer was “do what you think is best doc”.

    Inside OR, there were so many other things that are less than ideal and often “damning’ to surgeons. I’m pushed to use a manual drill because we don’t have a sterilizer fit for my power drill. No pneumatic torniquets. No reduction clamps nor suitable retractors. And did I say before we don’t have a c-arm or an intra-operative xray machine? None of the nurse assists is comfortable with my orthopedic instruments. If this surgery turned horribly wrong, I wouldn’t be surprised. So I made sure the patient knew exactly what are our risk and he too wouldn’t be surprised if this surgery go bonkers.

    I don’t know how the patient’s surgery went well despite these never ending list of “have nots. He went through the surgery knowing all of these and it went well, save for the surgeons’ anxiety and stress. I couldn’t sleep before and after the surgery knowing the odds we’re getting through. Frankly, I’m scared more than the patient but choice is something limited for us during those times. The need outweighs the risk.

    Nowadays, I stil encounter a few of these have nots in most of my ORs, and I’m just as scared as before. I always talk these oddities to my patients and secure their approval before performing any surgery on them under these situations. This doesn’t lessen my anxiety and stress level though. It just pushes me beyond my comfort zone trying out new things “unorthodox”  that are anchored on a logical framework I’m taught during training. Ultimately, need is such an impetus for innovation.

    So I wonder, does these insurmountable odds make us- the”provincial” cutters, less of a surgeon?