The Physician's "Squeeze"

As a person outside the medical community, I want to mention a couple of scenarios I've read about that are emerging in this country affecting physicians.  Much of this information is based on a report by Dr. Sandeep Jauhar (author of Intern: A Doctor's Initiation, 2009) in SaturdayEveningPost.com (Jan.-Feb.'15, pgs. 34-38, 78).

Let's start with where the U.S. ranks in life expectancy among developed nations - #45 - according to a report by The Commonwealth Fund, a healthcare research group.

If you live in Miami, Medicare will spend $8414/person/year versus $3341/person/year in Minneapolis. Why?  A large supply of doctors in Miami means more per capita utilization of services and testing, hospitalizations, and intensive care stays.

Doctors in this country are reimbursed for whatever they bill.  They're paid separately by insurers for patient visits.  As long as their patients are in the hospital, doctors can bill and be paid for each visit. In our healthcare system, "if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur."
(SaturdayEveningPost.com, Jan.-Feb., '15, p. 36).

Volume counts.  Fear of lawsuits creates volume in terms of services (some unnecessary) and referrals.  Better-informed patients might be the most potent restraint for over-utilization.

Here's the other side of the coin.  According to Dr. Jauhar, he was under pressure
at Long Island Jewish Medical Center to reduce the length of stay of patients
hospitalized with heart failure.  The shorter the patient's stay, the more the hospital's costs were reduced (associated with less use of hospital resources during a shorter stay).

It's a physician's squeeze.

The result?

Doctors are trying to sell their practices; uncompensated care is growing; admissions and elective procedures (money makers) are declining; and hospitals are cutting costs, staff, and services.

Dr. Jauhar suggests several options:
          - Hire doctors as employees and put them on salary, removing incentives to
            overtest
          - Use bundled payments for packages (an entire hospitalization, for example),
            rather than discrete services
          - Move to an "accountable care organization" in which teams of doctors would
             be responsible (and paid) for patients' clinical outcomes.  Most doctors have
             performed poorly in such situations. (pg. 38)

A recent Time magazine article by Steven Brill  (Jan. 19, 2015) suggests another option:
          - The University of Pittsburgh Medical Center's model (Brill also cites the
            Cleveland Clinic's model, a 75-facility enterprise)
             in which hospitals, doctors, clinics, AND INSURANCE COMPANY would be
             under one roof.  Tight regulations for these conglomerates, mostly through
             use of
             federal anti-trust laws and state regulatory authority, would ensure their
             accountability.  The in-house insurance company
             would have the incentive to control the doctors' and hospitals' costs
             AS WELL AS the means to do so. There would be less incentive to
             inflate costs or overtreat, because the in-house "boss" would get the bill
             through the insurance company.





 
       

How Not to Get Sick(er) in the Hospital

This is a recap of a Consumer Reports article of the same title, February, 2015, pages 32-37.  The information reinforces the experiences I relate in my book, ELDERLY PARENTS WITH ALL THEIR MARBLES: A SURVIVAL GUIDE FOR THE KIDS. In a future blog I'll discuss the physician's "squeeze."

TO INCREASE THE ODDS OF A GOOD HOSPITAL EXPERIENCE:

- Check infection rates at local hospitals before surgery.
   Go to www.LeapFrogGroup.org to check
   hospital performances on
   patient safety, high risk procedures, and intensive care.

- Pick a medical team that will involve you in decisions
   about your care and respect your capacity to make
   those decisions.

-  Make clear to the staff you want to be treated with patient respect and dignity.
   Among 1,200 recently hospitalized people surveyed by Consumer Reports,
   29% said they rarely received respect from the medical staff.  Those patients were
   2 1/2 times more likely to experience a hospital-acquired infection, a wrong
   diagnosis, an adverse drug reaction, or a prescribing mistake.

   Respectful treatment includes:
   Doctors minimizing use of medical jargon or explaining it
   Staffers introducing themselves before doing anything else
   Doctors and staff listening to your concerns, answering questions, honoring your
       wishes
   Medical teams acknowledging mistakes and treating you like a person

   If a patient doesn't think the staff is listening or his wishes aren't
   being met, he'll hesitate to ask questions, point out mistakes, or communicate
   in ways that could improve his situation.

   "The safest hospitals," according to a group of Harvard Medical School doctors and
   researchers as reported in Academic Medicine (journal), "share core values of
   transparency, accountability, and mutual respect."

   "Every day almost 2,000 people on average pick up an infection in the hospital and
   about 1,100 preventable drug errors occur.  Hospital medical errors are linked to
   440,000 deaths annually."

   The greatest danger for a patient in the hospital is NOT 
   infection or drug error.  
   It's REMAINING SILENT!
   Patient (or advocate) engagement
   has been nicknamed
   "the blockbuster drug of the century."

IF YOU'RE A PATIENT IN A HOSPITAL:

- Let a nurse know the extent of your pain.

- Find out what tests and procedures are for.

- Ask about drug side effects and interactions.

- Be a person to the staff, not a diagnosis.  Talk about your family or personal details

  about your life.

- Invite doctors to have a seat and look at them in the eye to initiate direct
  eye contact away from an electronic device or clipboard.

- Bring an advocate with you (family member, friend, health care proxy, 

   health care manager) to make sure you're comfortable, to get information 

   from the doctor written down, to help you make decisions, to speak for you 

   if you aren't able.  The advocate should meet the head nurse, attending physician, 

   therapist, and aide.

- Have an advocate with you when the most hospital errors occur (shift changes 

  and care transitions).

- Keep a journal and pen or e-device for questions and notes.

- Make a list of questions for the doctor when he makes his rounds.

- Ask your questions but try not to alienate the doctor or staff.

- Ask a doctor to repeat himself if you don't understand. 

- If you don't see your doctor or nurse wash his/her hands, make a respectful request

   that he does so.  Gloves don't necessarily stop the spread of infection.

Many thanks to my friend Al West for passing this article along to me!

   

                                         
 

My Father's Voice

This guest post is by pharmacist, author of murder mysteries, and friend, Don Weiss. 

My father died on August 8^th, 1982.  I was 30 years old.  The day of his funeral dawned hot and sunny. I was amazed at the number of people who showed up at the cemetery. People whom I knew and people who were perfect strangers. The common denominator, my father had touched these people’s lives in some way. Enough so that they wanted to honor the man they knew in life.

My dad was a member of Tom Brokaw’s “greatest generation.” He served honorably in World War II as a combat field medic, earning a purple heart and a bronze star at the age of 24. 

What I remember about my dad was his sense of humor, his humility, and how he had the ability to make you feel safe when he was around. He was completely dedicated to his sons and his wife, and worked twelve hours a day for as long as I can remember. I can still remember the sound of his car pulling into the driveway and how good that felt.

Going with dad to see the Phillies play at old Connie Mack Stadium and going with him to watch the Eagles play, and the day he took my brother and me to the zoo (to give my mother a break). Trips to the Franklin Institute and the Academy of Natural Sciences and never protesting when my mother would plan a family outing on my dad’s only day off.

When I was a rebellious fifteen year-old, I mouthed off to my father. He smacked me across the face at something faster than the speed of light. It wasn’t a hard slap; it was more for the shock value, but boy did it get my attention. It was the first and last time it happened and with the exception of a brief spanking when I was little, it was the only other time that my father laid a hand on me.

My dad would never come to the table unless he was showered, shaved and dressed and I never saw him get something from the kitchen without asking my mother if he could get her anything.

When I was seventeen and still rebellious, my dad suffered his first of three heart attacks. Two years earlier he was diagnosed with Parkinson’s disease. Both began to rob dad of his vitality and I had to grow up fast to help my mother care for him.

He recovered well enough to go back to work, but he wasn’t the same guy. On the eve of his second heart attack, I was home when it happened. With dad in the backseat, I drove the car to the hospital. Again dad recovered enough to go back to work but three years later at the age of 60, he retired on disability. He cooked meals and did other work around the house as much as his physical condition would allow. On rainy days, he would wait at the bus stop for my mom holding an umbrella. Three years later he succumbed to his third heart attack. Parkinson’s had taken a huge toll on him as well, and he was only a shell of the man that I knew.

My huge regret in life is not spending more time with my dad during those last years. I had moved away seven years earlier and only got to see my folks two or three times a year. I wish that I could have talked with him more. The last words I spoke to him were “Hi dad, how are you?” All he said was “I’m fine; I’ll put your mother on.”

Now that I’m going through my own period of self doubt, I can only guess at what advice father would give me.  All I can hope for is that I’m as good a man.

Happy Holidays to All!

May your blessings be many,

May your worries be few,

 Happy Hanukkah, Merry Christmas, 

And a bright New Year too!
Take strength from a smile, a hug, or some zest,
Return it and see why you'll feel at your best!

Thank you for reading my blog and my book,

This silly rhyme also,

With photos they took!

Wishing everyone a healthy 2015 with some laughs thrown in!            Fondly, Pam

Camilla and Charles Babysit While the Royals Visit the Colonies

Charles:   For the love of heaven, what is that beastly smell?

Camilla:    It's Prince George's biggie.  He just finished his lunch.

Charles:   Can't you do something?                                                                  

Camilla:   Sedrick (butler) is bringing rubber gloves and an apron.  Should I order you
               a mask?

Charles:   No, just get it done.  Oh no, oh no!  He just vomited over my velvet
               slippers.  It's vile - it's green.

Camilla:   It's just peas, Charles.  Kate said to give them a try.  Here's Sedrick now.
               Help me get the Prince out of the highchair, would you, Charles?

Charles:  Sedrick, I need a wet towel right away.
               You know I have a bad back, Camilla.  I can't lift him - he's a load.

Camilla:   And I just had my nails done.  Come on, give me a hand.
               (they both lift Prince George)

Charles:   Stop squirming, son!  My god, he's heavy.  I can't hold him.
               (Prince George and Camilla fall sideways onto carpet)
               Holy Queen Mother!  Are you hurt, Camilla?

Camilla:   (slightly winded)  George fell on top of me.  Get his doctor!
               (Prince screaming on top of Camilla)

Charles:   Where is that nanny when we need her?  Where's Sedrick?
                Oh, there you are, Sedrick..  There's been a fall.  Summon the Prince's
               doctor immediately.
                Not a word of this, mind you!
                (takes wet towel as Sedrick retreats again for doctor)
                Take deep breaths, darling.  The Prince will be fine.  He had a soft landing
                on that lovely bosom.  (Prince George's cries turn to whimpers)
                Up-a-daisy, now.

Camilla:    (on her knees, handing Prince George to Charles)
               Oh, my nails are ruined!  Where is that nanny?

Sedrick:   (reappearing)  The doctor's on his way.  I'll take the Prince to his nanny.

Charles:    And do something about that odor, will you, Sedrick?
                Some spray, perhaps?
                I need to calm down.  Where's the paper, Camilla?

Camilla:     I need to get an appointment with my manicurist.

Charles:    (scanning paper)
                Look at this, Camilla!  They're in Brooklyn, of all places, for some brutish,
                smelly game. There's a monster with his arm around Kate.
                Didn't he get the protocol sheet?
             
Camilla:    (looking at news photo)
                She's making the best of it with that smile.  Always a good girl.
                William doesn't notice - his eyes are on Beyonce.

Charles:    Leave it to the Yanks to create a tempest.

Camilla:    We didn't need a Yank to create a tempest, did we now, Charles?

Charles:    Don't go there, Camilla.  Here they are at a gala.  I wonder what that
                 frock cost the Treasury?

Camilla:    It's elegant and covers her baby bump. Frumpy's all you get in
               The Pretty Pregnant Boutique here.

Charles:    Maybe the next one won't eat like a gargantuan or poo like a horse.

Camilla:    Her stylist outdid herself with those five 'do's.  Are they going away again
                soon?

Charles:   If they must, we'll be heading off in the opposite direction!




             


           
           
           

A Favorite Christmas Memory

My husband comes from a large Irish family in Massachusetts.  To be specific, he is the oldest of five brothers and twin sisters.  Among the next generation are eleven grandchildren (and now twenty-three great-grandchildren).  The clan gathered at Granny’s house for every holiday except July 4^th, when we were all at the beach.        

On Christmas Eve we piled the car with presents for each niece and nephew and Charley’s parents, and then all of us piled in – Charley and me, our two boys, my parents, and sometimes my sister and her husband. On this particular Christmas Eve, Granny and Grandpa were living in a two-story cottage.  It consisted of a kitchen, small dining and living room, and an enclosed sun porch.  Upstairs were two bedrooms and a bathroom.

With the temperature near zero, we spilled out of the van into the kitchen, hugging and kissing whoever was there and spilling their drinks in the process. We dropped our presents under the tree, leaning down to kiss each niece and nephew as we passed.  One nephew weaved a new Big-Wheel among the legs of the adults, screeching like a siren as he went.  A two-year-old pulled the bell on his new fire engine as he made his way to a fire. They’d been unable to wait.

Granny had the buffet set up in the dining room, where smells mingled from baked ham, lasagna, sliced roast beef for sandwich-making, sweet potatoes, and Granny’s famous potato salad.  My sister-in-law Joanne brought her blueberry and pecan pies and one of Charley’s sisters brought a cake.  Sugar cookies decorated with red and green crystals waited for the kids.

The tiny living room bulged with a love seat, a lounger, and folding chairs.  My parents and my sister squeezed together on the love seat.  I headed for a drink in the kitchen. “Time to eat,” Granny announced.

A hungry mob almost ran me over, stampeding toward the dining room.  With drink in hand, I followed and eventually found the arm of the lounger as my place to perch.“Can we open our presents now?” the grandchildren begged who hadn't received riding toys.  They'd only eaten a couple of bites.

The sound of ripping paper and screeches of joy filled the tiny living room, as our sons and their cousins found their gifts under the tree. Parents couldn't keep up with who'd given what to whom.  Torn paper and ribbons soon littered the floor.  Adults who weren't parents pinned themselves against the outer extremities of the walls.  Amid the chaos, a dispute broke out between two cousins.  "Mine!" yelled the little one, trying to dislodge his older cousin from the seat of his Big Wheel.  He used his only defense mechanism - he bit.  Teeth marks drew blood, howls filled the room, and Granny flew upstairs for iodine and a band-aid.


Eventually trash bags appeared amid the mayhem.  Parents stuffed wrapping paper and ribbons in dark green bags and attempted to round up their kids' toys into a family bag.

At midnight we got our gear together and dispersed into the freezing cold.  The inside of our noses stuck together. Charley’s brother's SUV was stuck in front of us and needed a jump start, which Charley provided.  The two of them ran into the warm refuge of the kitchen, where the rest of us waited. 

We arrived home around 2 a.m. to grab a few hours' sleep before Santa’s appearance.  Thankfully, we'd already put together all the gifts with small parts.  My exhausted parents, sister, and brother-in-law pulled themselves upstairs.

The next morning after Christmas breakfast we opened our gifts and retrieved the bag from Grandma’s house.  Anticipating their new hockey gloves and head phones, the boys discovered only wrapping paper, tissue, ribbons, and torn gift cards!  We’d taken home a bag of garbage.

Thirty years later, I remember the laughter more than any of our missing gifts.

Patience Brewster, artist and designer of handmade ornaments and holiday decor (http://www.patiencebrewster.com/ornaments.html), helped inspire this
holiday memory.           

Grandma's Instructions

Grandma had to go out while the grandchildren were visiting in Florida.
Here are the instructions she left for Grandpa.

             DO:                                                             

 1. Become a mannequin for "Beauty Parlor"
     game      
 2. Check for BARRETTES in your hair before
     leaving the house
 3. Lock the bathroom door, if you must use it
 4. Put the phone in Hannah's pocket so she
     can call me if you fall asleep and begin to
     drool                                
 5. Put any colored pills on
    an unreachable shelf so they
     won't mistake them for jelly beans.
 6. Sneeze only if absolutely necessary
    and into your elbow or you will
    be told you are spreading germs
    and a demonstration will follow of the
    appropriate method
 7.  Keep an extra pair of glasses in
    a locked drawer and write down
    where the key is.  Story-time follows
    snack-time.
 8. Make time-outs a learning experience
    about right and wrong, but place them in
    a chair that isn't
    near wallpaper they can peel.  
 9. Use microwave only.  No
    ovens!                                            

            DO NOT:

 1. Take the children within 50 feet of the
    ocean
 2. Take the children within 20 feet of the pool
 3. Reheat pizza for lunch AND snack-time
 4. Tell them about starving children
    around the world to make them finish their
    meals.        
    When Olivia tells you she's
    allergic to fish and peanut butter,
    BELIEVE HER!
 5. Let the children out of your sight for more
     than one minute, tops.
     That includes toilet time, so pee
     frequently and in small amounts.
 6. Try to shower
 7. Assume any sporting event on t.v.
    will keep them fascinated for three hours
 8. Pretend you heard something they
    said when you didn't.  Your response will
    make no sense and they'll think
    a nut case is in charge.
 9. Allow more than 2 carousel rides or Olivia
     will throw up
10. Assume they can buckle their own
      seat belts, but follow their instructions if
      you can't figure out how to do it
11. Frighten them by raising your voice for
      any reason. When you think you're
      whispering, you're actually speaking
      loud enough to be heard in a hurricane.
12. Believe them when they tell you they
      aren't tired and can skip a nap
13. Wear your "comfort outfit" or your fanny pack out of the house
14. Attempt to explain where babies come from or whether there's
      a Santa Claus.