When pain persists: what makes hospital patients really unhappy? | Ranjana Srivastava

A ninety-year old woman has lain shrivelled and uncomfortable in her bed for forty hours, awaiting an operation. She has become heavily constipated as a result of an over-enthusiastic prescription of anti-diarrhoeal tablets and is now at risk of a bowel obstruction.

The surgeon says that the hardened faeces need to be manually evacuated under anaesthetic but it’s the weekend and only one operating theatre is open, with a bevy of surgeons desperate for the same limited resources. My patient doesn’t speak English and I don’t speak Polish but the language of starvation and defeat is universal.

No words of consolation will relieve her of the suspicion that she has been abandoned because she is old. Her bleary-eyed, septuagenarian son, wants her to taste a piece of her birthday cake because today might be her last birthday.

“Doctor, can my mother have cake?”

If she fasts, the surgery might happen. But if she eats, it definitely won’t. If she has the surgery, she might die. But if she doesn’t, she might also die. I wish he didn’t have to ask the question and I wish I didn’t have to answer it.

I have already argued with the surgeon, who is a trusted friend, and who is even more upset than I am, asking me to imagine how he feels when patients and doctors blame him for delaying surgery when he spends entire weekends biding his time to get into theatre.

“But you’re the surgeon,” I say. “Who has the authority to open another theatre?”

“Bureaucrats, who don’t work weekends.”

I am driving home hopeless and helpless when a colleague calls. “My hospital says patient experience surveys rate me as being in the bottom percentile of providers. How can this be when I give my heart to medicine?” This from a woman whose greatest concern during a difficult pregnancy was who would look after her patients when she took maternity leave.

She is surprised when I laugh, “You can’t be at the bottom because I am!”

Soon, we are swapping stories of doctors who are equally stumped by surveys that call into question their approach to patient care and seem to put the blame at their feet for not doing better.

One might have thought good medicine was always about the patient but patient experience surveys are the latest trend in healthcare. Done at significant cost and with good intention, they seem reasonable enough. After all, in order to address the matter, it’s important to know what makes patients unhappy.

As the saying goes, a happy patient can still be a dead patient

But poor patient experience surveys must be an executive’s nemesis. Pleasing political masters means performing magic and making the problem vanish, preferably before an election comes around, but addressing the cause is a lot like peeling an onion, uncovering layer upon layer of challenge that makes one weep.

Firstly, patient experience is not the same as patient satisfaction. A patient who is shaken awake every four hours might be in a rotten mood the next morning but those neurological observations might just have saved her life.

A patient denied jam on his toast might say the service stinks but better a grumpy diabetic than a comatose one. As the saying goes, a happy patient can still be a dead patient. But patients aren’t naïve and many understand the clinical imperatives that determine their experience.

Whether it’s waiting hours in the emergency department, being stuck on a trolley, facing delay in surgery or awaiting chemotherapy, very few patients make an actual fuss – because they see that doctors and nurses are doing their best.

Indeed, the neediest patients tend to complain the least – perhaps because they are tired but also because their experience of chronic illness has taught them patience and empathy. No, this should not be an excuse for provider complacency.

For most patients, a genuinely poor experience results from a lack of communication and a failure of compassion. Combine deferred surgery, lying in a trolley, a cancelled appointment and a hurried consultation with a lack of decent explanation and no acknowledgement of suffering and you have a real problem with patient experience.

A poor patient experience is leaving an incontinent patient wet because there is a shortage of nurses and when a confused patient can’t be fed because the nurse has two hands and five patients. It’s when you can’t reach your water jug, and when you do, it’s empty. It’s being desperate for a hot tea, a warm shower and a working call-bell. When patient dignity suffers, there are no winners – a bad patient experience is a guilty provider experience. Realising this isn’t rocket science but ushering change is really hard.

Hospital medicine is increasingly conducted amid apologies

Every frontline clinician knows that no amount of ward redesign, geographical shuffling of patients or imaginative rebranding will solve the fundamental problem of having fewer doctors and nurses on the floor to deal with increasingly complex patient needs. Studies show that extra staffing of registered nurses improves patient outcomes. Nurses flag early signs of deterioration, help patients mobilise safely, and step in when doctors don’t or won’t communicate effectively. Having good nurses on the ward transforms the environment – interns feel secure, specialists feel supported, and patients benefit from earlier discharge and lower readmission rates.

An ageing population has placed an unprecedented demand on allied health services like physiotherapists and social workers but it seems as if no one saw this coming. Try finding a service on a weekend and you could be waiting all day.

“If your patient isn’t homeless or destitute right this minute, I can’t get to it,” apologised one lone, harried social worker covering an entire hospital.

Heart and kidneys don’t wait for a quiet weekday to fail. An appendix doesn’t wait for an available theatre to burst. Tottering patients don’t know not to fall on a Sunday. Clearly, infrastructure and planning are not for an individual doctor to fix but when hospitals perform poorly, the spotlight shines inevitably on doctors.

Hospital medicine is increasingly conducted amid apologies. I am sorry you can’t have your operation today. I am sorry the morphine took so long. I am sorry you have vomit-stained clothes. I am sorry your son left before a doctor could get here.

The apologies are necessary and it’s humbling that they heal more than mere words should, but apologies without action slowly erode us because we know that tomorrow will be filled with more apologies and so will the day after and the day after that. Those who engage with patients know that you can’t soothe and trick people into thinking they are getting better care – you actually have to provide it. But as long as bureaucrats answer to politicians and clinicians answer to patients, the tension will remain.

Some people just leave. “I get paid better for a different headache,” says one surgeon, who quit the public system after ten years of battling a dysfunctional outpatient system. But many others stay, in part due to a philosophical belief that their exceptional training should benefit the least well-off in society. It is especially these doctors and nurses we want to shield from disillusionment.

Having observed healthcare delivery in some of the best institutions in the world, I have been struck by one observation. It’s when executives regularly make time to visit the wards and interact with patients, families and all manner of providers, from physicians and nurses to porters and aides.

They peer into a decrepit bathroom, pick up a flimsy frame, sit in a wobbly chair, taste the tepid tea – and discover what makes for a poor patient experience. A clinician leader who doesn’t see patients frequently loses touch with their most human concerns. A non-clinician heading finance, operations or human resources, is never exposed to the daily realities of human suffering yet is charged with making far-reaching decisions that impact all our lives. The best leaders make it a point to keep their finger on the pulse – and society is better for it.

Patient experience surveys are here to say, and in time, to financially reward organisations and individuals who do well on them.

But to truly improve patient outcomes organisations will have to do more than probe patients and fault doctors. To borrow from the drug advertisements, when pain persists, organisations will need to talk to their doctors.

But then, they will need to listen.

When pain persists: what makes hospital patients really unhappy? | Ranjana Srivastava

Staff Unhappy With Wellness Benefits As Companies Lower Back

As a lot more businesses minimize back on healthcare rewards and increase deductibles, workers do not like these corporate cost-shifting moves to workers, according to a new survey of much more than five,000 complete-time staff by skilled companies consulting giant Towers Watson (TW).

For many years now, a key method of employers is to shift charges onto employees via larger deductibles and co-payments in component to slow the growth of the complete business-paid premium by obtaining staff to consider twice just before selecting an costly check or procedure in hopes these staff become greater buyers. Individuals moves are translating into quick deterioration in the percentage of employees who are pleased with their well being advantages.

Even though nearly 3 and five workers are content with their well being rewards, the percentage has declined from 69 percent in 2007 to 59 % in 2013. Towers Watson said the “downward trend is most pronounced amid older staff and people in bad overall health.” The biggest percentage drop was amongst employees 50 and older with 56 percent pleased with their well being positive aspects in 2013 in contrast to 71 % in 2007.

“While staff depend on and value their well being care advantages, they are plainly not happy about their overall health care expenses,” mentioned Towers Watson senior consultant David Speier in a statement accompanying the report. “Rising healthcare costs have prompted employers to shift a larger share of health care expenses to staff, a lot of of whom are previously feeling financially stressed from the economic downturn and advantage cutbacks.”

An employer’s share of well being fees is projected at $ 9,560 in 2014, which is up 27 percent from $ seven,486 in 2009, according to a research earlier this 12 months by Towers Watson and Nationwide Organization Group on Overall health, a coalition of employers.  Meanwhile, the employee’s share of total overall health strategy charges jumped 32 percent during the same time period to $ 2,975 this 12 months in contrast to $ two,262 in 2009.

“At a time when charges are consuming a important share of their family spending budget, it is no shock that workers are significantly less willing to trade some pay out for both much more generous overall health positive aspects or a lot more predictable fees,” Speier explained.

But regardless of employee gloom about their wellness positive aspects, employees are happier with their company-sponsored retirement positive aspects, which is specifically notable at a time when retirement protection is increasingly essential to employees.

Towers Watson’s survey signifies staff really feel so strongly about their retirement safety that 62 % of employees are prepared to give up some pay out for a “guaranteed retirement advantage.”  And workers are even much more prepared to pay a lot more for retirement advantages than for their overall health care coverage.

Pondering how health advantages will be affected by Obamacare? The Forbes eBook Within Obamacare: The Repair For America’s Ailing Wellness Care Program answers that query and much more. Accessible now at Amazon and Apple.

Staff Unhappy With Wellness Benefits As Companies Lower Back

It really is Worse To Be A Chemist -- And Other Responses To Unhappy Doctors

Yesterday’s post, trying to reconcile heartfelt doctor concerns about the evolving practice of medicine with information suggesting far more students than ever are pursuing medication as a job, obviously touched  a nerve,  drawing  a assortment of thoughtful responses, numerous from Twitter.

I was encouraged by the amount of medical doctors who wrote that on balance, almost everything is (even now) (quite) amazing.   It was especially heartening to hear this view from front-line physicians, like my former colleague Jamie Beckerman (“As a front-liner myself, I couldn’t think about undertaking anything at all else. I adore it every single day.”) and San Francisco internist Urmimala Sarkar, “There IS some thing specific and unique about medicine. Fortunate and grateful in #primarycare!”

Academic and policy-oriented doctors, such as Ashish Jha and Aaron Carroll, were if anything, far more emphatic.  Their fundamental viewpoint: physicians have it actually good and need to stop whining.

On the other hand, some thoughtful critics mentioned that several of these most enthusiastic about medication aren’t performing it all of the time.  Maybe these “part-time” docs (or worse, individuals like me who are now non-training docs) can idealize and glorify health care practice precisely because they’re not in the trenches, fighting the battles each and every day.  (I’d like to believe I’m reasonably attuned to current concerns – see right here, here.)

Some critics also recommended that potential med students and young trainees may not actually know what they are getting into (“Applicants do not know any greater,” 1 respondent grumbled) – or may not hear the suggestions they get.  “Every Dr I know says they wouldn’t do it more than once again but they ignored the same suggestions as students,” tweets biologist Ken Fortino .  Additionally, as VC and doctor Justin Klein factors out, “It’s difficult to enjoy the nature of the task until finally you do it.”

The usually-thoughtful (and fellow Forbes physician contributor) Ford Vox (see this recent gem) pointed out that physician satisifaction may depend a whole lot on exactly where you are functioning – and of course he’s appropriate.  My current PCP, at One particular Healthcare Group, looks far less harried than my preceding PCP, and tells me that a important purpose she joined One particular Medical was exactly for the opportunity to practice medication in a fashion that is significantly less rushed and closer to her unique best.  The opportunity for a more fulfilling practice is a draw not only for conventional concierge practices (or concierge-light practices like One Healthcare), but also for innovative primary care practices this kind of as Rushika Fernandopulle’s Iora Wellness.  Although happier doctors are likely to consequence in far more pleased individuals, this might not inevitably translate into improved outcomes (a disconnect this recent Onion story wryly observes).

The need for standpoint was advised by UCSF doctor-scientist Ethan Weiss: “I believe getting a physician is still great. It is currently being a scientist I am concerned about,” and even much more poignantly by former business chemist John Tucker: “The bloodbath amid my peers in latest many years has possibly made me excessively intolerant of the complaining.”  As VC Nimesh Shah nicely summarizes, “versus the avg working American it is nevertheless a nicely paying out work with exceptionally minimal unemployment.”

Possibly my favorite response was from AliveCor founder and cardiologist (and my 2013 Digital Well being Entrepreneur Of The Year) Dave Albert, who notes that his wife “works 4 proto-ACO, gripes about Epic &amp loves getting a doctor” and “our MS2 [second-year health-related pupil] son heard all the horror stories. Picked medication (most likely IM[internal medication]) over Investment Banking.”

Probably there is hope for medicine’s long term soon after all.

It really is Worse To Be A Chemist -- And Other Responses To Unhappy Doctors

A Unhappy Day For Organized American Psychology

December 31, 2013 was a unhappy day for organized American psychology. That was the day the American Psychological Association, under the quiet cover of a pending holiday, announced it would not more investigate an ethics complaint towards a psychologist for his participation in a well-dcoumented brutal interrogation at Guantánamo Bay.

The APA letter announcing the decision was published by the Guardian. In response, Frank Summers, the existing President of the Division of Psychoanalysis (aka, Division 39) of the American Psychological Association, wrote a response. It plainly exposes the APA’s ethical failing. With Dr. Summers permission I am posting the full text of his letter here:

—————

February 12, 2014

Lindsay Childress-Beatty, JD, PhD
Director of Adjudication/Deputy Director, Ethics Office
American Psychological Association
750 First Street, NE
Washington, DC 20002-4242

Stephen Behnke, JD, PhD
Director Ethics Workplace
American Psychological Association
750 1st Street, NE
Washington, DC 20002-4242

Dear Drs. Childress-Beatty and Behnke:

I am writing on behalf of Division 39 to express grave concern over the choice of the Ethics Committee to take no action on the ethics complaint towards Dr. John Leso regardless of his role in directing the torture of Mohammed al-Qahtani.  I note that the letter to Dr. Trudy Bond explaining the choice does not dispute Leso’s involvement in the torture that left al-Qahtani in an incoherent, hallucinatory state that State Division representative Susan Crawford acknowledged was a “life threatening predicament.”  No 1 disputes the fact that Leso consulted on and directed the torture of Mohammed al-Qahtani.  Dr. Leso recommended the torturers in a assortment of techniques, like excessive heat, light, cold, darkness, and loud noise, as properly as sleep deprivation, isolation, forced nudity, prolonged anxiety positions, a variety of forms of humiliation, and other torture methods.  At times Leso was in the space offering directions to those implementing the torture.  The barbaric treatment of al-Qahtani is the most nicely documented situation we have of the US torture system begun under the Bush administration after 9/eleven and the clearest, most indisputable evidence of the participation of a psychologist in torture. As far as is recognized, his mental state has never returned to standard.

The only rationales for the selection had been: (1) Dr. Leso “did not request to grow to be involved with detainee interrogations but was rather informed that he would be in the part of behavioral science consultant only after he arrived in Guantanamo Bay in the summer of 2002,” (two) the military lacked a normal working process for the BSCT function, and the APA did not nevertheless have an articulated policy on interrogations and, (three) there was pressure from the Bush Administration to use “enhanced interrogation techniques” and Leso reportedly spoke out against their deployment.

To excuse Leso on the grounds that he did not know he was going to be concerned in interrogations is equivalent to saying that a psychologist guilty of sexual misconduct is to be absolved if he did not intend to abuse the patient sexually when he started to operate with her.  Nothing in the ethics code allows an ethical principle to be violated with impunity because the intent was not there from the commence.

The 2nd alleged mitigating circumstance is that neither the military nor the APA had presented a policy for interrogations at the level that Leso was torturing al-Qahtani.  But, the principle of “Do No Harm” was in operation given that the beginning of the Ethics Code.  The letter makes no mention of the fact that the APA Ethical Ideas of Psychologists and Code of Conduct starts with Principle A: “Psychologists strive to benefit those with whom they work and consider care to do no harm.  In their professional actions, psychologists look for to safeguard the welfare and rights of these with whom they interact professionally and other impacted persons….” Absent from the Ethics Office letter is any mention of the harm Leso inflicted on Mohammed al-Qahtani.

Moreover, the basic principle of “Do No Harm” is fortified in Normal 3.04: “Psychologists get affordable steps to keep away from harming their clientele/sufferers, students, supervisees, analysis participants, organizational clients, and other people with whom they function, and to minimize harm in which it is foreseeable and unavoidable.”  That principle alone is enough to sanction a psychologist who participates in the torture of anybody, specifically illegally held detainees. To absolve Leso on the grounds that there was no policy on “enhanced interrogations” is equivalent to saying that a psychologist who locks a patient in a closet for two days without foods or water can not be sanctioned since the APA has no “closeting policy.”  How can it be that Leso’s participation in performing egregious, potentially irreparable, harm to al-Qahtani, does not render Leso guilty of violating each Principle A and Regular three.04, fundamental ethics concepts of the code?  Similarly, the truth that Leso allegedly “argued against” Bush Administration pressure to use “enhanced interrogation techniques” in no way mitigates the reality that he tortured al-Qahtani any much more than the truth that a Nuremberg defendant who after opposed the Nazi celebration would be discovered not guilty for crimes committed although a Nazi. The United States did not get critically the defense of “I was just following orders” at Nuremberg and nevertheless that identical excuse would seem to be invoked by the Ethics Office as a justifiable rationale for egregious violations of the Ethics Code in the situation of torture by a psychologist.

The APA has maintained from the inception of this situation that it would investigate any fees that psychologists have been concerned in unethical conduct.  The Leso selection proves with undeniable clarity that is not the situation. The refusal of the APA Ethics Workplace to apply even minimal standards of ethics and human decency to Leso’s participation in torture demonstrates with crystalline clarity that the APA Ethics Workplace has no significant intent of ever sanctioning a psychologist who takes part in torture.

The consequences of the Leso determination are far reaching.  It sends a clear signal to all APA members that they can seek the advice of and direct torture with impunity.  Anyone concerned in violating the APA ethics code by inflicting harm on detainees in unlawful detention camps want not fear action from the APA.  None can take significantly the APA pronouncement that it stands in opposition to psychologists’ involvement in torture now that it is clear the APA refuses to sanction psychologists whose torture participation is indubitable.  The APA speaks with its habits: it permits the use of techniques defined as torture below international convention in clear opposition to its claim to oppose psychologists’ participation in torture.

In addition, by refusing to hold accountable a psychologist who participated in a brutal, destructive torture approach that obviously, dramatically, and starkly violates the most standard rules of APA’s personal ethics code, the Ethics Workplace and Ethics Committee have relinquished their moral authority to pass judgment on ethical malfeasance.  It could hand down selections, but people judgments have tiny ethical force now that the Ethics Office has refused to take action towards egregious torture practices. Provided that refusal to enforce the ethics code in a clear case of torture, what basis could the Ethics Workplace or the Ethics Committee perhaps have for obtaining any psychologist guilty of violating other ethical principles, most of which are not as damaging as torture?  For example, psychologists have been located to have committed ethical transgressions for accepting costly gifts or forming dual relationships with patients.  None would get seriously a judgment of ethical misconduct for this kind of habits by an organization that enables its members to participate in torture with impunity.

Moreover, the APA’s willingness to allow psychologists’ participation in torture is becoming watched by the international psychological neighborhood.   The Leso situation demonstrates to the psychological globe that the American Psychological Association does not have the integrity to be a leader in the planet neighborhood.  The respect the APA as soon as commanded about the globe has been eroding by its facilitation of torture, and the Leso situation hastens that fall in stature.

A Unhappy Day For Organized American Psychology