The Coming Healthcare Revolution: Take Control of Your Health

book.

PREFACE

President Barack H. Obama

The White House

1600 Pennsylvania Ave

Washington DC 20500

Dear Sir:

I am an internist who was involved in direct patient care for forty years (biographic sketch enclosed). I am in favor of your efforts to expand healthcare to every citizen. The goal of eliminating or reducing the financial nightmare that many of us face is a laudable one. Seeking input from all stakeholders and listening to all viewpoints is necessary and commendable.

I do have concerns however. If we are to add the forty-seven million uninsured citizens to an already overburdened healthcare system, we may face a disaster of major proportions. Here are the reasons: The diminishing cadre of primary care physicians, already insufficient to provide for the current patient population, will not be enough to carry the sudden burden of an increased patient load. They are so busy involved in acute and chronic follow-up care that they have precious little time for one of the cornerstones of medical practice: the complete medical examination (a full and comprehensive medical history, a head to toe physical examination and basic laboratory analysis). Failure to diagnose has been one of the unfortunate results. There is nothing more important to the practice of medicine than this initial physician-patient interaction. Because of this shortcoming, another cornerstone of medical practice, prevention and early detection, has also suffered. Physicians have precious little time to concentrate on this crucial aspect of medical care. I agree with your emphasis on prevention and early detection—and it must be a priority in any future healthcare system.

Now that I have pointed out a few of the problems, I would be remiss if I did not offer solutions. You are aware of the shortage of primary care physicians. Patients need more of these dedicated physicians. We must build the foundation to accommodate this increasing patient load as soon as possible consistent with the tenets of good medical practice

Physicians will need assistance to carry out the cornerstones of medical practice described above. There is no reason why well-educated nurses and physicians assistants cannot perform the complete medical examinations and provide the counseling necessary to carry out early detection and prevention. I worked with nurses in this capacity and I can attest to the fact that they were exceptional. With the physician as captain of this ship, freed up to concentrate on acute and follow-up care and the more urgent and serious cases, every office can become a complete physical examination, risk factor analysis and early detection and prevention center as well as an acute and chronic primary care office. I leave it to the economists to determine reimbursement mechanisms.

I also suggest that physicians, nurses, physician assistants and other healthcare workers need protection from the avalanche of malpractice lawsuits that are overwhelming the system. This will require modification of your stance on tort reform. When I was consulting in Europe (see biographical sketch), I asked the physicians how malpractice was handled. They replied that there is a mediation board set up to take care of the patient’s present and future needs. I believe an approach of this sort is necessary if you want the support of the healthcare community.

Thank you for your attention.

Wishing you success in your efforts, I am sincerely yours,

Sheldon Cohen M.D. FACP

I wrote this letter to the president while he was waiting for a healthcare bill to be on his desk by the end of the week. I believe most physicians share the sentiments expressed in my letter. I received a Dear Friend thank you note signed by the president. Subsequent events put roadblocks in the plan, but I am hopeful for a solution.   Time will tell what form it takes. Patients must be prepared to take control. It is hoped that this book will show them why it is important to do just that, plus provide some education about the complexities of the art and science of medical practice and the patient’s role in helping to make it as fool-proof as possible.

FROM THE AUTHOR…ABOUT THIS BOOK:

I write books as a hobby and in an effort to stay abreast of medical issues, a daunting task in these days of rapid medical advances. Writing also helps to keep one’s mind mentally stimulated as old age slowly and inexorably creeps up. That plus physical exercise (I walk a dog every day) gives me a leg up on prevention according to well-accepted research.

I write in many different genres including medical non-fiction, medical fiction, World War II and Jewish historical fiction, terrorism, and have written a series of short books with many different sub-titles under the heading of The Slim Book of Health Pearls.

Healthcare in the United States is now on the threshold of a major historical change. Obamacare, or the Patient Protection and Affordable Care Act will require much more of patients now suddenly thrust upon an already overburdened and overcrowded medical care system. It becomes more important than ever to TAKE CONTROL OF YOUR HEALTH!

With this in mind, and in view of the above impending changes, I decided to take four of my Slim Book of Health Pearls series and incorporate them into one book, all with the goal of assisting the patient in the daunting task of navigating through the coming healthcare changes and taking appropriate steps to control risk. The four steps are:

1. The Prevention of Medical Errors…Step 1

2. The Complete Medical Examination…Step 2

3. Risk Factor Analysis and Health Screening…Step 3

4. Symptoms Never to Ignore…Step 4

As a patient, your role in navigating through these four headings is crucial because.

• Medical errors are pervasive and dangerous and can injure or kill. You need to know what they are in order to take preventive measures.

• The complete medical examination in today’s medical environment is often incomplete and the source of many failure to diagnose malpractice law suits. You need to know what the complete exam entails and insist on its implementation.

• Risk factor analysis and health screening is a crucial part of an initial patient evaluation, but is often incomplete or ignored. Patients can perform this important risk factor analysis on their own and learn the proper timing of health screenings.

• Patient delay in evaluating symptoms is a dangerous procrastination that you must avoid.

The book will amplify each section in detail.

I would be remiss if I did not add one personal warning about the coming healthcare system. Tort reform, in the new healthcare changes to be, is conspicuous by its absence. As the thousands of pages of changes come into effect, and as more and more physicians abandon private practice to take on salaried roles, and as the medical system in the United States approaches the more socialized system of other countries, which I firmly believe is inevitable, the absence of tort reform, similar to the system of other countries poses the risk of collapsing the system, both medically and financially.

STEP 1: THE PREVENTION OF MEDICAL ERRORS

Es Irrt Der Mensch, So Lang Er Strebt

(As long as human beings strive, they will make errors)

Johann Wolfgang von Goethe

(1749-1832)

Introduction

A medical error has occurred anytime a healthcare provider plans a medical action and it does not succeed as intended, or the wrong plan is used. These errors can include problems in medical practice, failure to diagnose, procedural problems, system failures, or product deficiencies.

Ninety-eight thousand people per year die from medical errors, a number that represents more deaths than occur from automobile accidents or breast cancer. This statistic, published by the Institute of Medicine in 1999, has prompted efforts by the Joint Commission on Accreditation of Healthcare Organizations to focus the accreditation process on operational systems critical to the safety and quality of patient care.

What is the Institute of Medicine? Who are its members? Are they a governmental organization? What is the funding source?

The federal government created the National Academy of Sciences to serve as an advisor on scientific matters. However, the Academy and its associated organization (e.g. the Institute of Medicine) is a private, non-governmental organization that does not receive direct federal appropriations for their work. The Institute of Medicine’s charter establishes it as an independent body. They use unpaid volunteer experts who author their reports, each of which undergoes a rigorous and formal peer review process that must be evidence-based where possible, or noted as an expert opinion where not possible. Many meetings of the Institute of Medicine are open to the public, or the committee may deliberate amongst themselves until they reach consensus. Any potential conflict of interest could disqualify a committee member.

One cannot dispute this committee’s findings—the best minds are at work. In addition, the Joint Commission considered it serious as well, for they have launched a nationwide effort to minimize medical errors in healthcare organizations.

Let us define what medical errors are. The Joint Commission has categorized a long list of hospital errors that have resulted in death or injury, the so-called sentinel events. This is necessary so that the Joint Commission can investigate and make sure that hospitals have put systems in place to prevent the error from reoccurring. These sentinel events are:

Anesthesia related: Death or injury may result from anesthesia.

• Delay in treatment: Failure to diagnose in time, treatment delays resulting in disability or death and wrong diagnoses are all medical errors. An incomplete medical examination is often the reason.

• Elopement: Serious injury or death could result when patients leave facilities of their own accord before diagnosis.

• Infection-related: Lapses in sterile technique may result in an infection.

• Maternal deaths: Obstetrical deliveries may result in injury or death.

• Medical equipment: Medical equipment failures may result in disability or death.

• Medication error: Physician, pharmacist, or patient error may result in injury or death due to improper or wrong medication use.

• Operative/post-operative: Complications may result from surgical or post-surgical care.

• Patient abduction: Infant abduction from newborn nurseries have occurred.

• Patient falls: The failure to identify the fall-risk patient, and/or the failure to safeguard the patient may have serious consequences.

• Perinatal deaths/injury: Injuries or death may occur around the time of birth.

• Potassium Chloride: The accidental direct intravenous injection of potassium chloride can result in cardiac arrest.

• Restraint deaths: Restraints are a last resort to protect patients from themselves and staff from patients. Restraint use is only for the shortest time necessary and includes frequent monitoring. Failure to monitor these patients may result in medical complications or death.

• Suicide: Guidelines must be in place to identify and monitor the suicidal patient.

• Transfusion: An improper matching of a blood transfusion can cause injury or death.

• Ventilator: Mechanical ventilation is often necessary to breathe for patients who are unable to breathe for themselves. Improper ventilator settings, machine failure and incomplete monitoring may result in death.

• Wrong site surgery: Wrong-site surgery can result from failure to identify the precise surgical site.

• Wrong test performed: Improper orders or failure of interpretation of orders will result in the wrong test.

Medical errors do not only happen within hospitals. They can occur in any healthcare facility including outpatient surgery centers, clinics, doctors’ offices, nursing homes, pharmacies and patient’s homes. In fact, home care fires are another sentinel event claiming victims over age sixty-five in most instances. Risk factors identified are:

Living alone

1) Absence of a working smoke detector

2) Flammable clothing

3) Home oxygen

4) Cognitive impairment

5) Smoking has been a factor in all cases reported

An incomplete medical history and physical examination will result in failure to diagnose. The same is true of an incomplete screening laboratory analysis and risk factor analysis. This is a crucial part of any physician-patient interaction from the diagnostic standpoint, and there is nothing more important for creating rapport and a lasting, trusted relationship between the physician and the patient.

When a medical error has occurred there has been a breakdown of one or more of the built-in safety measures put in place to prevent such mishaps. These safety measures are the responsibility of the entire healthcare team. Physicians must get involved by making certain that patients are educated and made to take responsibility for their care. Patients must understand that they are not a passive member of the team. They are the most impopatrtant member. They must feel free to ask questions and satisfy themselves that the medical diagnostic and treatment option they choose is the best one taken for an optimal result. They must take control!

There are basic steps any patient must take when confronted with a new diagnosis that has long-term future impact. These are:

Learn all that is possible about the problem or problem

• Speak with the physician or other member of the healthcare team

• Get information from the internet or books

• Look to support groups for assistance

Only then will patients be in a position to decide upon a treatment plan. Physicians want their patients to do this. Careful evaluation of all the risks and benefits will produce a satisfied and fully informed patient who will adhere to a well-planned proper course of action, best suited to their individual mind-set.

Medical errors are:

• Medication prescribing and use

• Medication use during care transitions

• Patient identification

• Performance of correct procedure at correct body site

• Communication during patient handovers

• Control of concentrated electrolyte solutions

• Catheter and tubing connections

• Infection control

• Diagnostic errors or failure to diagnose

Patients can and must assist in prevention. This book will provide clinical examples that illustrate the error discussed and the patient’s role in prevention.

Medication prescribing and use

When a physician writes a prescription, it must be legible. If it is not, the pharmacist may have difficulty. If a patient cannot read the prescription, rewriting it is mandatory, or, at least, spelled out in writing. Sound-alike medications with similar spelling have been confused, so patients must be alert less they receive the wrong medication. There are also look-alikes, and generic medications made by different manufacturers may have a dissimilar appearance. Therefore, the moral of the story is—if there is an issue about any medication, clarify it before taking the medicine.

The busy pharmacist could misread the medication or confuse it with a medicine with a similar sounding name. The use of pharmacy technicians is common. Failure of the pharmacist to check everything the technician does has also caused prescription errors. This complicated process must be double-checked.

When a physician sees a patient, the patient should bring a list of all medications prescribed by all physicians. Some larger clinics and University Medical Centers will have a full medication list printed out for patient evaluation and confirmation. If not, then patients must come prepared either with a full medication list including vitamins, herbs and dietary supplements, or with a brown-bag with the medications. Physicians will appreciate this help and realize they are dealing with an educated and informed patient. Patients must be wary of physicians who do not think this way.

Example: A patient suffered from sleep apnea that she could not control with the recommended C-pap therapy. This is a breathing assist mechanism to prevent obstructive breathing. A dental appliance, another form of therapy, also did not help. The patient did much of her own research, and was more aware of all the physiological mechanisms of sleep apnea then most physicians. Out of desperation, she saw another doctor in consultation. And when the patient told this doctor about all the research she had done to understand her illness, the doctor stopped her and asked, You do research on sleep apnea? The astounded patient said, I want to know about my problem. That’s the doctor’s job. he said, That’s not for patients to do." Her inclination was to get up, say thank you, and leave, but she did not. She asked me what I thought. I told her, at that point, you would have lost all confidence in that doctor, and I would not have blamed you if you did just as your inclination suggested, thank him, left, and found another doctor.

Patients must be certain that every physician they see in consultation is aware of any medication allergies. This is the only way to avoid receiving a medication that may cause harm. No physician can know what any patient may or may not be allergic to. Prescribing medication is a gamble, and will remain so until the era of personalized medicine (see appendix 3).   At this time, a doctor does not know what any medication’s effects will be on any individual patient.

Case in point:

A patient had open-heart surgery. His doctors prescribed numerous medications. Prior to surgery his blood count was normal, and after surgery his blood count was reduced. The blood loss during surgery should have resolved and gone back to normal within weeks of the surgery, but it did not; in fact, it continued dropping to lower levels. His doctor sent him to a hematologist who, thinking of all kinds of rare diseases, recommended that he have a bone marrow biopsy. The patient decided to hold off on this procedure while he did his own personal research. He went on the internet and studied his medications, all of whom had the rare potential of causing anemia. Could this be it, he thought? Is one of the medications causing this? After understanding the possible risks of delay and getting approval from his doctor, he stopped the last medication prescribed that was for prostate symptoms and repeated his blood count after one month. Lo and behold, it was back to the pre-surgical and normal fifteen grams. He had had a rare side effect of a medication prescribed for his enlarged prostate. This information now occupies a prominent place on his medical chart. He saved himself a bone marrow biopsy, and his hematologist learned something too.

If patients are allergic to any medication, it is wise to wear a wristband identifying the offending agent.

Patients must know the following when given a prescription:

• What is the medicine and what does it do?

• How long must it be taken and at what intervals?

• What are the side effects to watch out for? If they occur what must be done?

• Are there any potential drug-food interactions that may cause a problem by enhancing or hindering the action of the medicine?

• Are there any activities to avoid while on the medication?

Pharmacists must provide information about each medicine they dispense. The patient must read this information and have questions answered before ingesting the medication.

With liquid medication, a marked syringe