Clinical judgments, not algorithms, are key to patient safety—an essay by David Healy and Dee Mangin. When it comes to detecting harms related to drugs, clinicians’ and patients’ judgment trumps trials, say David Healy and Dee Mangin. Failure to realise this is the greatest threat to the safety of medicines Immediately on taking a selective serotonin reuptake inhibitor (SSRI), most people have some genital anaesthesia.1 This may be aggravated on withdrawal of the drug and can remain for years after treatment has stopped, constituting post-SSRI sexual dysfunction (PSSD).2 The first case of PSSD was reported to regulators in 1987, even before fluoxetine was approved.
While sexual dysfunction features in the labels of SSRIs, neither genital anaesthesia nor PSSD does. The fluoxetine label states that “there are no adequate and well-controlled studies examining sexual dysfunction with fluoxetine treatment.” The citalopram label acknowledges “some evidence suggests that SSRIs can cause such untoward sexual experiences.”
Time To Change The 15-Minute Limit For Doctor Visits. Some patients, such as Felipe Finale (pictured here), the man who received the world's smallest pacemaker, may get more than 15 minutes with his doctor. But for many patients, a 15-minute visit is the norm. (Photo by Joe Raedle/Getty Images) Who said that 15 minutes is enough time for a doctor to examine and take care of a patient? According to a Western Colorado radio station, KOOL 107.9 FM, this is roughly the same amount of time men spend on the toilet each day, which could increase depending on what you eat and how much toilet texting you do. Patient care is probably more complex than taking a dump (i.e., you don't need as much training to poop). The reason is insurance reimbursement, which dictates a lot of what is done in medicine.
(Work RVU x Geographic Index + Practice Expenses RVU x Geographic Index + Liability Insurance RVU x Geographic Index) x Medicare Conversion Factor The purpose of this now archaic formula was to reduce the variability in physician fees. From Sweden to Texas via the IHI National Forum: Do-It-Yourself Dialysis. My team thought I was crazy. The year was 2011. I had just returned to my practice at Central Texas Nephrology Associates in Waco, Texas, after attending the most recent IHI National Forum. I was bursting with enthusiasm about what I’d learned there. My colleagues were used to my post-Forum excitement. We had just started our journey toward patient-centeredness and quality improvement after I attended my first IHI National Forum in 2006. But this year was different. SIGN UP: Attend the IHI National Forum at the early bird rate through September 30. Christian and the nursing staff went on to teach many other renal patients how to dialyze themselves.
As a kidney doctor who had been practicing for over 30 years, I was very familiar with the typical dialysis set up and monitoring — what I call “hunker-down dialysis.” Instead of just sitting quietly, this Swedish clinic’s patients were connecting themselves to the machines and doing things like exercising during their dialysis! Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. - PubMed - NCBI. Extending the Applicability of Clinical Practice Guidelines to Patients with Multiple Chronic Conditions – Minimally Disruptive Medicine. This is a reprint of a previous publication held on guidelines.gov. We will work to update information within in coming blog posts. By: Aaron L. Leppin, MD and Victor M.
Montori, MD, MSc Currently, half of all American adults have a chronic disease and 1 in 4 live with the burdens of multiple, concurrently active chronic conditions (1). The Dilemma for Clinical Practice Guidelines Clinical practice guidelines, for scientific and practical reasons, orient themselves around the management of specific diseases or clinical circumstances. Although all patients exist in unique biopsychosocial contexts, the care of patients with MCC is particularly complicated by the interaction of multiple, concurrently active chronic conditions. Guideline developers who desire to incorporate and encourage this understanding face a key dilemma.
Consider Stanford’s Chronic Disease Self-Management Program (CDSMP), for example. The Opportunity for Person-centered Guidelines Recommendations for Consideration Authors. Do Hospital Visitors Impact Patient Outcomes? | Clinical Correlations. By Brit Trogen Peer Reviewed In 2001, the Institute of Medicine’s Crossing the Quality Chasm became the seminal paper recognizing patient-centered care as a crucial component of overall health care quality.[1] Since then, patient and family centered care (PFCC) has been increasingly recognized as a valuable model for improving patient outcomes, facilitating communication, and increasing satisfaction with care.[2] Open and flexible visitation policies are a major component of many PFCC programs and have been widely embraced by hospitals throughout the US [3] However, the impact of family presence on patients and hospital staff is complex, with varying impacts on patients, family members, and hospital staff.
But visitors also bring potential risks. Equally concerning is the potential negative impact of open visitation policies on hospital staff. Brit Trogen is a 3rd year medical student at NYU School of Medicine Reviewed by Michael Tanner, MD, Associate Editor, Clinical Correlations 1. Association of Clinician Denial of Patient Requests With Patient Satisfaction. - PubMed - NCBI. Findings from a feasibility study to improve GP elicitation of patient concerns in UK general practice consultations - Patient Education and Counseling. Understanding What Is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients' Perspectives. - PubMed - NCBI. Doctors, Revolt! But Dr. Lown identifies first and foremost as a healer. In 1996, he published “The Lost Art of Healing,” an appeal to restore the “3,000-year tradition, which bonded doctor and patient in a special affinity of trust.” The biomedical sciences had begun to dominate our conception of health care, and he warned that “healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures.”
He called for a return to the fundamentals of doctoring — listening to know the patient behind the symptoms; carefully touching the patient during the physical exam to communicate caring; using words that affirm the patient’s vitality; and attending to the stresses and situations of his life circumstances. This time he was the patient in need of healing. Despite his reputation, Dr. What he needed was “the feeling of being a major partner in this decision,” he said. The medical team was concerned that because Dr. I had known Dr. The art of conversation - The Lancet. Patient perspectives | The College of Family Physicians of Canada. How Design Thinking Is Improving Patient-Caregiver Conversations.
Executive Summary Technical developments tend to grab the headlines in health care. Predictive analytics, telemedicine, electronic health records — technology is rightly seen as a transformative force in health delivery. But it’s not the only one. At Rotterdam Eye Hospital, hospital administrators have found that through their ongoing design-thinking program, lower-tech measures can improve patient outcomes. Such simple measures as building a more intuitive website, replacing harsh fluorescent lighting and cold linoleum floors with softer lighting and wood parquet, and giving children and pediatric ophthalmologists matching T-shirts have all served to reduce patient fears.
Addressing patients’ fears is important because they can make an eye operation difficult or even impossible. Rotterdam Eye Hospital has integrated a measure that is even lower-tech: better conversations. Technical developments tend to grab the headlines in health care. But it’s not the only one. Improving patient care using clinical guidelines and judgement. Guidance to clinicians on patient care has increasingly become institutionalised through clinical practice guidelines (CPGs).
Dictionaries define a guideline as a suggestion for behaviour, but clinicians have strong incentives to comply with these guidelines when they are issued, making adherence to them almost compulsory. A patient's health insurance plan may require adherence as a condition for reimbursement of the cost of treatment. Adherence may also be used as evidence of due diligence to defend a malpractice claim.
The medical literature contains many commentaries exhorting clinicians to adhere to guidelines. They argue that CPG developers have a better knowledge of treatment response than clinicians. As Institute of Medicine (2011, p.26)) states: "Trustworthy CPGs have the potential to reduce inappropriate practice variation. " Statements like this demonstrate the widespread belief that adherence to guidelines is socially preferable to decentralised clinical decision-making. Assessing the Burden of Treatment.
The missing person: The outcome of the rule-based totalitarianism of too much contemporary healthcare - ScienceDirect. <div pearltreesdevid="PTD138" role="alert" class="alert-message-container"><div pearltreesdevid="PTD139" aria-hidden="true" class="alert-message-body"><span pearltreesdevid="PTD140" style="display: inline-block;" class="Icon IconAlert"><svg pearltreesDevId="PTD141" style="width: 100%; height: 100%;" width="24" height="24" focusable="false" tabindex="-1" fill="currentColor"><path pearltreesDevId="PTD142" fill="#f80" d="M11.84 4.63c-.77.05-1.42.6-1.74 1.27-1.95 3.38-3.9 6.75-5.85 10.13-.48.83-.24 1.99.53 2.56.7.6 1.66.36 2.5.41 3.63 0 7.27.01 10.9-.01 1.13-.07 2.04-1.28 1.76-2.39-.1-.58-.56-1.02-.81-1.55-1.85-3.21-3.69-6.43-5.55-9.64-.42-.52-1.06-.83-1.74-.79z"></path><path pearltreesDevId="PTD143" d="M11 8h2v5h-2zM11 14h2v2h-2z"></path></svg></span><!
-- react-text: 58 -->JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page. <! -- /react-text --></div></div> Abstract Objectives Methods and results Conclusion Practice implications Keywords Person. Sharing control of appointment length with patients in general practice: a qualitative study. Familiarity breeds better outcomes.
Let’s be clear: familiarity breeds better outcomes. People who have a usual, continuous source of primary medical care generally do better than those who don’t. We know this, and yet everywhere primary care and general practice are in crisis. The United Kingdom is no exception. Its medical schools are “training future doctors for yesterday,” say our editorialists John Oldham and Sam Everington (doi:10.1136/bmj.j294). What is it that general doctors do so well?
Despite the best efforts of primary care doctors, every year millions of people visit a hospital emergency department. Because there are so many emergency department visits, the authors calculate that this small percentage translates into 10 093 deaths a year in the US. The Heroism of Incremental Care. By 2010, Bill Haynes had spent almost four decades under attack from the inside of his skull. He was fifty-seven years old, and he suffered from severe migraines that felt as if a drill were working behind his eyes, across his forehead, and down the back of his head and neck. They left him nauseated, causing him to vomit every half hour for up to eighteen hours. He’d spend a day and a half in bed, and then another day stumbling through sentences. The pain would gradually subside, but often not entirely. And after a few days a new attack would begin. Haynes (I’ve changed his name, at his request) had his first migraine at the age of nineteen.
He saw all kinds of doctors—primary-care physicians, neurologists, psychiatrists—who told him what he already knew: he had chronic migraine headaches. Migraines are typically characterized by severe, disabling, recurrent attacks of pain confined to one side of the head, pulsating in quality and aggravated by routine physical activities. Pause. “Now?” Ask patients “What matters to you?” rather than “What’s the matter?” Sosena Kebede, assistant professor of medicineAuthor affiliationsskebede3@jhmi.edu This can help reframe interactions in a more patient centered way Maureen Bisognano, one of the keynote speakers at this year’s International Forum on Quality and Safety in Healthcare in Gothenburg, Sweden, told delegates that we should ask our patients, “What matters to you?”
Rather than, “What is the matter?” The question “What matters to you?” Tries to get to the essence of patient centered care, which the Institute of Medicine has listed as one of the priorities for quality improvement. As physicians, our success in treating illness depends mostly on our ability to diagnose what the matter is with the patient. The emphasis on diagnostic skill sets alone, however, has led … The Values and Value of Patient-Centered Care. + Author Affiliations CORRESPONDING AUTHOR: Ronald M. Epstein, MD, Center for Communication and Disparities Research, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, Ronald_Epstein@urmc.rochester.edu Key Words: Patient-centered care has now made it to center stage in discussions of quality.
Enshrined by the Institute of Medicine’s “quality chasm” report as 1 of 6 key elements of high-quality care,1 health care institutions, health planners, congressional representatives, and hospital public relations departments now include the phrase in their lexicons. Insurance payments are increasingly linked to the provision of patient-centered care. Patient-centered care is a quality of personal, professional, and organizational relationships. Confusion about what patient-centered care really means, however, can produce efforts that are superficial and unconvincing.
Second, many of the measures confound behaviors with outcomes, leading to confusing results. Footnotes. Journal of Clinical Nursing Seeing the person behind the patient enhancing the care of older people using a biographical approach. “Nudge” in the clinical consultation – an acceptable form of medical paternalism? Can consumers learn to ask three questions to improve shared decision making? A feasibility study of the ASK (AskShareKnow) Patient–Clinician Communication Model® intervention in a primary health-care setting - Shepherd - 2015 - Health Expectations.
Abstract Objective To test the feasibility and assess the uptake and acceptability of implementing a consumer questions programme, AskShareKnow, to encourage consumers to use the questions ‘1. What are my options; 2. What are the possible benefits and harms of those options; 3. How likely are each of those benefits and harms to happen to me?’ These three questions have previously shown important effects in improving the quality of information provided during consultations and in facilitating patient involvement. Methods This single-arm intervention study invited participants attending a reproductive and sexual health-care clinic to view a 4-min video-clip in the waiting room. Results A total of 121 (78%) participants viewed the video-clip before their consultation. Conclusions Enabling patients to view a short video-clip before an appointment to improve information and involvement in health-care consultations is feasible and led to a high uptake of question asking in consultations.
Box 1. The importance of being different (Family Practice) - McWhinney. Making EBM work for individual patients. Margaret McCartney, general practitioner1, Julian Treadwell, general practitioner2, Neal Maskrey, visiting professor3, Richard Lehman, senior advisory fellow in primary care4Author affiliationsCorrespondence to: M McCartney margaret@margaretmccartney.com Margaret McCartney and colleagues argue that new models of evidence synthesis and shared decision making are needed to accelerate a move from guideline driven care to individualised care A Google Scholar search using the term “evidence based medicine” identifies more than 1.8 million papers.
Over more than two decades, evidence based medicine has rightfully become part of the fabric of modern clinical practice and has contributed to many advances in healthcare. Guidelines grew out of a need to communicate best current evidence to clinicians, but their limitations are often not explicitly stated (box 1). Box 1: Problems with applying population based evidence to individuals Randomised … How Person-Centered Is Your Health Care Organization? Taking patient-centred health care from rhetoric to reality. Caring with evidence based medicine. Medical Facts versus Value Judgments--Toward Preference-Sensitive Guidelines. A survey of primary care patients' readiness to engage in the de-adoption practices recommended by Choosing Wisely Canada. Symptoms as the main problem: a cross- sectional study of patient experience in primary care | BMC Family Practice | Full Text.
Doctor Yearns For Return To Time When Physicians Were 'Artisans' “Informed choice” in a time of too much medicine—no panacea for ethical difficulties. Making evidence based medicine work for individual patients. What Do Physicians Tell Patients About Themselves? Iora Health pioneers new primary care model. Origins - Medicine of the Person. The possibilities of patient-centered medicine. If Patients Only Knew How Often Treatments Could Harm Them. In the patient’s best interests? Who says? Empowering the elderly in Japan: lessons for home care in Canada. The Paternalism Preference — Choosing Unshared Decision Making. Ellipsis: Seeing My Way to "No" (Guest Blog by Alan Schroeder) Smuggling a Beer for My Hospital Patient - The New York Times. What is WrapAround?
A challenge for new doctors: Focus on the patient, not just the symptoms. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations | The BMJ. Five Keys to 'Less Is More' Medicine in the Clinic. Ten Commandments for patient-centred treatment | British Journal of General Practice. A Doctor's 'People Skills' Affects Patients' Health. The 6 questions every good doctor should ask you. Visit-specific expectations and patient-centered outcomes: a literature review. Harvard Studied People For 75 Years & Found That Happiness Comes From One Thing... A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families -- Southwick et al. -- BMJ Quality and Safety.
Amy Price and Marilyn Mann on the pros of patient peer review. What If Everything You Knew About Disciplining Kids Was Wrong?