Sunday, September 26, 2010

Loose lips

Hi, fellow health-care providers! Were your ears burning this week? They should have been, because people were talking about us.

Earlier this week, I met a man who, while not a health-care worker, is involved in a provincial health organization. Our conversation came around to a recent experience he had while one of his family members was being cared for in a local emergency department. His opinion was that there was a lack of professionalism demonstrated by the staff – physicians and nurses – in that ER. He had no complaints about the care provided to his relative. What troubled him was the seeming lack of concern for patient privacy and confidentiality.

He said it was impossible to ignore loud discussions that included details of other patient’s medical history and treatment, as well as staff’s “editorial comments” of their impressions about a patient’s demeanor. Some whispered comments were followed by laughter, which he admitted could have been innocent, but naturally made him wonder if some patients were being ridiculed.

His family member was admitted to hospital where he observed similar incidents on the ward. He was particularly annoyed that he regularly heard staff discussing their social lives at length, presumably while “on the clock”.

His final comments were that he was reluctant to raise his concerns with staff because he worried that it might have repercussions for his relative’s care, and also that he wondered who was responsible for overseeing appropriate staff behaviour.

Ouch! The truth hurts.

I’ve been guilty of these lapses, and see them regularly in the ER, hospital wards and other patient care areas. But, my first impulse was to explain to this man – who didn’t work in health-care – why this behaviour is sometimes unavoidable.

First of all, certain patient care areas – especially ERs, recovery rooms and critical care areas – bring together multiple patients, their families and medical staff in a confined space. Because staff needs to closely monitor the patients’ conditions, it’s not always possible to step away to a more private area to discuss care. Also, in order to be efficient, it’s sometimes more convenient for staff to have conversations about patients in the hallway outside a ward room, rather than searching for a more private spot.

However, I didn’t offer these reasons to the man, because my heart wasn’t in it. I knew they were more excuse than reason. We can do better. This experience had obviously affected his confidence in health-care providers, and empty explanations would only compound the problem.

Later in the week, I attended a meeting of our health region’s Patient and Family Centred Care advisory council. We heard a presentation about a proposed change in the ERs with the implementation of an electronic “white board”. Many ERs use a white board to keep track of patient status, pending tests, tentative diagnosis and consultations requested. While intended for staff use, they are often posted in very visible locations that anyone can see. As we move toward using a district-wide electronic medical record, these white boards will be replaced with large computer monitors that display the most current information about each ER patient. For example, if blood test results are ready, an alert would be displayed, letting staff know immediately that results can be reviewed. At present, staff need to remember to check intermittently to see if results are back, and this delays the next step in diagnosis and treatment.

While current (and proposed electronic versions) white boards don’t display patient names, that’s small comfort. Bed numbers are shown, so it’s easy to match the patient to the diagnosis. We rely on the anonymity granted by being a large urban centre, and the fact that it’s unlikely that ER visitors will know anyone who is currently being treated. But, what about smaller towns? And, good luck to you if you are a health-care worker being treated in the ER of your own workplace.

Imagine this scenario: You’re a consultant called down to the ER to see a patient. As you walk in, you see a colleague lying on a stretcher. As you walk by the white board, are you going to take a quick peek at his bed number to see what’s going on? Even if there isn’t a diagnosis given, you can see what tests are pending, and which medical service has been consulted. Cardiology? Uh-oh, probably a heart attack. Psychiatry? Hmm, interesting. Are you going to take a peek? No? C’mon, really?

The electronic white boards would not identify patients and, as was explained to us, the symbols on them would be somewhat cryptic so as to foil easy interpretation by unauthorized viewers. Well, short of using Klingon, I’m not sure we’ll have much success in disguising the symbols’ meaning. In any case, we don’t want staff to be confused as to their meaning as that would defeat the purpose of displaying them in the first place.

As one of the council’s community members pointed out, families might actually find white boards useful as a way to monitor their relative’s status and progress in the ER. In order to do that, they would need to understand the information and would naturally ask medical staff what it all meant, thus exposing the status of all ER patients.

Several community members commented that they would accept the display of patient information if it would improve the efficiency in the ER. Hearing that comment made me realize that we (health-care workers) are framing discussion about privacy issues in a way that makes patients and families feel that they are obliged to accept violation of their privacy in return for efficient and high-quality care. The impression that our community representatives had (because that’s the impression we gave them) was that, if we don’t prominently display private patient information, an ER can’t function properly. Take it or leave it. And, of course, when put like that, they’ll take it.

But, it’s a false dichotomy. There are more than 2 choices here. The beauty of digital information is that up-to-date data can populate many different devices simultaneously. We don’t need a Jumbotron blurting out patient status. Instead, display it on desktop monitors and iPhones. That’s my quick take on how to address the problem – someone else has likely solved it more elegantly. My point is that we shouldn’t ask patients to give up an important aspect of their care because it will be simpler (for us) to maintain the status quo. As another community representative put it, patients shouldn’t have to “settle”.

Now, back to the first gentleman’s observations about medical staff’s behaviour. He didn’t confront anyone at the time because he didn’t want his relative’s care to be affected. He also mentioned that he thought it wouldn’t make any difference even if he did raise it with the offenders. His rationale was that if people were far enough out of touch with appropriate professional behaviour that they were compromising privacy, they probably had a mindset that would not react well to criticism. Our system forced him to “settle”.

I asked him how he would fix the problem. He suggested that senior staff should be setting an example, by insisting that conversations take place in private locations, or at least by keeping voices low and being aware of who is within earshot.

Great idea, but not so easy to do. This behaviour is so much a part of our local culture that I think even senior staff would hesitate to be perceived as being critical of colleagues’ behaviour and labeled as “oversensitive”.

Maybe having staff hear about privacy concerns in patients’ and families’ own words would have an effect, in the same way this gentleman’s story had an effect on me. We could solicit feedback from clients regarding their impression of how their privacy was respected while they received medical care. Two or three questions would probably do it. This wouldn’t be a secret undertaking. On the contrary, we would inform staff that the survey was going on, and that they would see the results.

And, of course, we would post the results for the public to see. On the white board.

Sunday, September 12, 2010

The dark side of pooled referrals: Let's play monopoly!

After reading yet another post extolling the virtues of pooled referrals, an anonymous reader asked: “If all the urologists in Saskatoon work in a group practice in one clinic, how can a patient get a second opinion, without causing any unintended displeasure to the first physician?”

Great question! Plenty of meat on that bone.

There’s a simple answer for our group, a longer discussion about physician attitudes toward second opinions, and a dilemma around consolidating medical (or any service, for that matter) into one source.

First, let me address the reader’s actual question. In our group, patients are welcome to seek a second opinion from another member of the group. As the reader points out, we’re the only urology group in Saskatoon and, other than one urologist in Prince Albert, the only ones in the “north” of the province. While patients are free to travel anywhere in the province (or out of the province, or country) to obtain a second opinion, we recognize that this may be a significant burden for some and so provide the option inside our group. (Some may prefer not to seek second opinion within the same group, for fear that our practices may be too homogeneous. Or, they may worry that we don’t want to contradict one another.)

That’s the quick answer, but I’d like to turn the question back to the reader and ask this: “Why do you assume that a physician would be displeased if a patient sought a second opinion?” It’s disingenuous to ask, because I know that some docs do get bent out of shape if someone asks to consult another specialist.

Patient care may suffer when patients fear that a request for second opinion may displease their doctor. Most obviously, the first physician’s diagnosis and/or recommended treatment may be incorrect. A fresh evaluation may reveal the true problem.

Even when the first physician’s assessment is correct, patient and physician may not have an established a relationship of trust and respect. This can be particularly important if treatment involves something as dramatic as surgery, where stakes are higher. If a patient is uncomfortable with the physician’s manner or demeanor, they may have a good technical result from treatment, but their overall experience of care will suffer.

It’s not unusual for patients to see me for a “stealth” second opinion, that is, they will be referred for assessment and not reveal that they’ve previously seen another urologist. (As our group shares an electronic medical record, they would have seen a urologist in another centre.) Their motivation is that they want a fresh viewpoint, and worry that I’ll take the shortcut of accepting the other urologist’s opinion if I have access to his/her notes. The problem with that approach is that there may be clinical information, test results or xray findings not made available to me. That results in unnecessary repeat testing, or incorrect assessment because of incomplete data.

So, if some physicians balking at requests for second opinions can harm patients, why would docs behave that way? Apart from the very rare case of Munchausen’s syndrome, where people feign illness to gain attention, or doctor-shoppers seeking prescriptions for narcotics, its hard to posit a logical argument against a second opinion.

However, logic doesn’t necessarily get in the way of behaviour.

Physicians may feel slighted by the request. We take pride in our professional ability and may be upset at the thought that someone has questioned our diagnostic acumen. The message here: I get it right every time.

Perhaps a physician is insecure about his ability. This may be subconscious, or a conscious realization of inadequate skills and/or knowledge that could be revealed under scrutiny by another physician.

Some docs may have financial motivations. If being paid fee-for-service, there is an incentive (particularly for surgeons) to keep patients in their practice. If a surgeon is flush with referrals, and has a long wait list for surgery, he has enough “inventory” to maintain his income. If not, he may be tempted to “maintain control” of patients.

Physician paternalism is another factor. Docs pride themselves on having their patient’s best interest at heart, even to the point of making decisions on behalf of the patient. They may see the request for a second opinion as a rejection of their caring.

As physicians, we need to remind ourselves that we don’t own our patients - they choose to consult us. The therapeutic relationship can be strengthened by our openness to seeking a second opinion, as it demonstrates our humility and willingness to learn, as well as our true concern for the well-being of our patients, rather than our egos.

The other issue this reader’s question raises is that of detrimental effects of consolidating medical services in one place. I’ve already flogged the benefits including efficiency, improved access and standardization of procedures. But, there is a dark side.

There have been practical problems for our patients, stemming from our practice structure. While we are open to patients seeking second opinions from within our group, there are circumstances where we have to end a relationship with a patient. This is rare, but there have been instances of personality conflicts between a patient and one of our docs that make it impossible for them to continue in a physician-patient relationship. Because our partnerships shares call and patient care responsibilities, our policy in those rare cases is that we decline to provide any care for that patient. They would then need to travel outside Saskatoon to obtain urologic care. Because of the significant burden that may place on a patient, we haven’t made that decision lightly and without considerable discussion.

Our group (and others like ours) is essentially a monopoly. Take it or leave it. Drive 3 hours to see another urologist. If you can get an appointment, that is.

Well, that’s not our attitude, but what if it were? What’s to stop any monopoly from doing exactly as it pleases for its own benefit? Customer be damned! And when I say monopoly, that could be our group, the entire medical profession, or the government-administered health care system.

In the case of medical groups, there are internal and external checks against degradation of service.

Internally, we rely on a culture of professionalism and altruism. This stems from our perception of our roles in society, and from behaviour we’ve internalized throughout our training and practice. In our group, peer expectations drive a desire to provide current and competent care. We (both physicians and office staff) pride ourselves on considering our patients’ needs and convenience. But, it’s also possible that a different culture could prevail, and lead to very different behaviour.

Externally, there are implicit expectations from peers, patients and society. Explicit expectations come from regulatory/licensing bodies that produce and enforce practice standards.

If internal influences weren’t working to maintain excellent standards of care, how would the external checks become involved? For example, what if we decided to “coast” on our knowledge and skills, and not offer the most current surgical techniques (and not inform our patients of the more up-to-date options)?

First, someone would need to recognize the problem. That may be our patients, but there is a significant inequality of access to information between patients and physicians (pace Internet), and I think it would be years before any but the most discriminating and ├╝ber-informed patient would realize anything was amiss.

Peer-review programs conducted by regulatory bodies would pick up some problems, such as gross misdiagnosis or out-of-date treatment. But, peer reviewers would be unlikely to identify quality problems such as poor access, as some are so pervasive that they are accepted as inevitable!

Patients may be reluctant to report a perceived problem for fear of being ostracized, tied up in red tape, or jeopardizing the sole source of medical care (no matter how inadequate) in their community.

When a monopoly’s internal culture fails to ensure appropriate service (or whatever its stated purpose may be), it falls to external influences to apply incentives. In the case of our practice, that would mean the health region, College of Physicians of Surgeons, or the courts. In the case of the entire country’s health care system, well, maybe someone needs to go all 1789 on it.

Thanks for the question!