Posts Tagged ‘Mayo Clinic’

Concussions in children

September 25, 2010  |  General  |  No Comments

Football season is upon us again, so it’s time to think about sports injuries. We frequently have children admitted to the PICU (or to what we call the intermediate or step-down unit) for observation, typically overnight, who have struck their head. They have had concussions. What is a concussion, and what does it mean for the child?

The term itself is centuries old, but even thirty-five years ago, when I was in training, the actual definition of concussion was a bit vague. What was usually meant was that the patient got hit on the head and either lost consciousness briefly or at least wasn’t quite himself for some period of time afterward. These days we’re more precise than that, but concussion is still a somewhat inexact term. This is mainly because of our ignorance of the subtleties of how the brain works.

The formal definition of concussion is a transient interruption in brain function. By implication, various scans of the brain, such as CT scans or MRI scans, show no abnormalities. Since all the imaging studies are normal, defining concussion is necessarily inexact. I’m sure one day we’ll have some kind of machine that detects the reason for the symptoms of concussion, but right now we don’t have such a thing — concussion is an entirely clinical diagnosis, meaning there’s specific no test for it.

There are several systems for grading concussions. Here’s how the American Academy of Neurology grades their severity:

Grade I: confusion, no loss of consciousness, symptoms last for < 15 minutes, has memory of the event Grade II: confusion, may lose memory of the event but no loss of consciousness, symptoms last for > 15 minutes
Grade III: loss of consciousness and no memory of the event

The list of symptoms that can come from a concussion is a long one. Headache, dizziness, vomiting, and ringing in the ears are common. Various behavioral changes are also common, such as lethargy, difficulty concentrating, and irritability.

What are the effects of concussion on a child? Years ago we pooh-poohed the idea that mild concussions cause brain problems. For example, football players were sent right back into the game after experiencing a concussion. We now know that is dangerous. As a general rule, we don’t recommend any contact sports for at least a week (some authorities say longer) after all symptoms have cleared. This is because a repeat blow to the head, even a very mild one, can cause severe injury to a brain that has not fully recovered from the last injury.

What about long term effects of concussions? The overwhelming majority of children who suffer a concussion, especially a mild one, recover completely. But around a fifth or so of children who have had severe concussions continue to have problems many months afterward.

You can read much more about concussions at this site, from the federal Centers for Disease Control, this one, from the Mayo Clinic, and this one, from the respected Brain Trauma Foundation.

What’s the electronic medical record (EMR) really for, anyway?

September 7, 2010  |  General  |  No Comments

This is a cross-post of an item I wrote for Maggie Mahar’s excellent heathcare blog, Healthbeat

The electronic medical record, the EMR, is upon us. For those of us who learned medicine entirely with paper charts, some have enthusiastically embraced the EMR and some have refused, to the extent they can, to deal with it at all. But most of us have plowed ahead into learning how to use it as best we can. It seems to me that the degree of enthusiasm physicians show for the EMR relates less to the particular version of it we have chosen (or, more commonly, was chosen for us) than it does to the kind of medicine we practice. The old paper records worked reasonably well for all of us; in contrast, the several versions of the EMR I’ve used work very well for some kinds of doctors, but less well for other kinds. I think a good part of this disparity is that the basic purpose of the medical record has changed over the past half-century or so, and some of these new roles can conflict with the old ones.

The oldest repository of continuous patient medical records is at the Mayo Clinic in Rochester, Minnesota. In a very real sense the modern medical record was invented there, in the first decade of the twentieth century, by Dr. Henry Plummer. As the first multi-specialty clinic, it made more sense for each patient to have a single record that traveled from doctor to doctor with the patient, rather than having each doctor keep his or her own record for each patient. The idea was to have a single packet of paper that contained everything that had happened to the patient. From that it’s only a short step to the notion that the record should travel with patients wherever they go, even if it is to physicians not associated with each other. This is a key promise of the EMR.

Medical records began as the possession of the doctor. This paradigm is changing. Very soon, although medical facilities will have copies, the records will essentially belong to the patient, with doctors only using them from time to time as need requires. Of course this could, in theory, happen with paper records, but it would be cumbersome. One of the things that first attracted me to pediatrics was the sheer size of the pile of paper that the medical records clerk would plop in front of the hapless medical student admitting an octogenarian to the hospital; in contrast, a toddler’s chart fits neatly in a small packet. The EMR allows these massive piles to be reduced to disks or microchips. It also allows the record to be organized into searchable form, so important things don’t get missed because they are buried in the disorganized mess of sequential folders.

Those are a couple of the brave promises of the EMR, but we all know we are a long way from realizing them. One huge barrier is that, as of yet, there is no standard platform for the EMR. Like many physicians, I’ve had to learn several because different facilities choose different vendors. In our pluralistic medical system (if one can indeed call it a system), it’s a free-for-all. And each of them has its own maddening quirks.

I think there is a broader problem here: over the ensuing years from Dr. Plummer’s era the medical record has taken on roles unheard of back then. For one thing, now the record is a legal document, a buttress against anyone who accuses us later of bad care. This process began long before the EMR, or course, which is one reason the charts I had to grapple with as a medical student ballooned so much. As a graduate student in history of medicine I had the chance to review many of the Mayo charts from earlier, simpler times. I recall one chart, from the nineteen-forties, describing the course of a very critically ill child. Overnight the child’s condition had markedly deteriorated; it was easy to see this from the recorded blood pressures and heart rates. The physician’s note for the following day analyzed these developments with only four words: “mustard plaster didn’t work.” Now the EMR offers the possibility of recording all we do easily and without getting writer’s cramp.

The medical record has also become something else it wasn’t back then: it is also now a commercial document, proof of what we did and why, used by payers to check up on us to make sure we should be paid for what we bill. Today’s payers want to know what the doctor did and why. They want to know, quite precisely, why that mustard plaster didn’t work and all that we did to make it work.

I think some of the problems with the promise of the EMR are that these legal and commercial roles can clash with the original purpose of the chart, which is taking care of the patient. The computer whizzes who design the software don’t always seem to me to have quite the same goals as we doctors who use it. The old paper charts were easy to adapt to new things, new procedures. All we needed was a different sheet to add to them and stuff in the folder. Upgrades and tweaks to the EMR are much more formidable things.

In spite of all these things I find the EMR to be a powerful addition to my practice. In fact, I think I’m a better doctor for using it. I think a key reason for that is because of what I practice – critical care medicine. In the ICU we love to measure and count things. We want minute-to-minute monitoring of variables, which in the old days resulted in huge paper flow sheets covered with dots and numbers. Rummaging through them to identify key moments in a patient’s care was often difficult. In the ICU, each patient gets a large number of tests each day, results which used to get stuck on clipboards with all the other paper. Important things got missed. Now I can sit at a computer screen and find it all with a mouse click, and the EMR makes it very hard not to notice anything important.

In contrast, I have friends who hate the EMR. It causes them hours of pain in training time, pain for which they aren’t compensated, and is slower for them to use than paper records were. In their minds, it gives them little or no advantage over paper in caring for their patients. I’ve noticed that they practice specialties that are less concerned with number-crunching than mine. They also tend to be office-based, rather then hospital-based, and don’t have to deal with as many other physicians as I do each day in the ICU. Thus many of their notes are written for themselves, not for other members of a large clinical team. Yet now they are asked to conform to how others want their charts to be.

I don’t know how all of this will work out. The EMR is here to stay. On balance, I think this will ultimately be good for doctors and their patients. But we don’t really know yet just what it is and what it should look like. I worry it will end up like one of those military boondoggles – it gets loaded with so many bells and whistles because it is supposed to serve so many purposes that it ends up being an expensive monstrosity that doesn’t perform any of its missions well.

Still, I’m an optimist. I prefer to be excited by the possibilities, rather than discouraged by the obstacles. I think the EMR will be good for patients, and will make us better physicians. For a while though, things will continue to be more than a little messy.

How should doctors be paid?

November 10, 2008  |  General  |  1 Comment

Most doctors are paid by some version of how they have always been paid–what is loosely called “fee for service.” The notion is simple: the doctor gets paid for each encounter with a patient, whether this is an office visit or a major surgical operation. Thus the more the doctor does, the more he gets paid. It seems fair. After all, shouldn’t we get paid for the work we do?

The fee-for-service model, however, has long had critics. The most fundamental objection is that it rewards doctors for doing things. In an environment like that, one in which the more one does the more he gets paid, the doctor is tempted to do things that don’t need to be done, or choose the thing to do for which he gets paid more rather than the thing that pays less. In the ideal situation, of course, the doctor won’t consider those things–rather, he will put the patient’s best interests first. But doctors are human, and fee-for-service presents a doctor with a fundamental conflict of interest.

The alternative to fee-for-service is some sort of payment system in which the doctor is paid a salary that is the same no matter how much he does. This is currently done by some large practices, including the Mayo Clinic. Critics of this salaried system believe that, without financial incentives, doctors will simply not work as hard. Other physician groups blend together the two approaches, with a salary supplemented by some sort of bonus for doctors who do more.

The debate is more than a financial one–it is also a philosophical one. Most free market enthusiasts strongly support fee-for-service; those who favor tighter regulation of medical care, often including one of various single-payer models, are typically open to salary-based payment models. Salary-model systems also are frequently used by Health Maintenance Organization (HMO) systems.

Historically, organized medicine has been strongly opposed to paying physicians by any other method than fee-for-service. Seventy-five years ago, physicians who accepted salaried arrangements were ostracized by their peers and sometimes even penalized. This view has changed to some extent, but I think it is still fair to say that most American physicians favor traditional fee-for-service.

For myself, I favor a salary model (or salary plus a modest incentive for extra productivity) for what I do. I work in the field of intensive care, which lends itself well to this. Other specialties are somewhat different. My job, in effect, is to be like a firefighter waiting in the firehouse–if the PICU is busy, I work harder; if there are less patients, I can ease up. After all, we pay firefighters whether or not they are fighting a fire.

I see no reason why physician payment strategies must be all one thing or all another. It seems to me that whatever evolves from our current chaotic situation could find a place for both approaches. Hard work should be rewarded. However, and this is a big however, we need to understand the inherent conflict of interest of traditional fee-for-service medicine. Also, not all rewards for hard work need be financial ones.

Online sources of medical information

June 30, 2008  |  General  |  No Comments

The internet has millions of bits of information, and some of it is even true. There are thousands upon thousands of blogs like this one; the only real way you can judge the truth of what I’m telling you, short of checking everything I write, is to either accept (or not) the weight of my credentials. As I wrote here, there are ways you can check on the reliability of what I’m telling you. You can also rely primarily on well-known (and well vetted) sites such as those of the Mayo Clinic.

Here is another extremely helpful site for you to bookmark. Titled the “50 Best Medical Libraries on the Web,” it is nice contribution put together by a nursing education site. What is particularly nice about the list of links is that they are grouped according to user, such as medical professional or general consumer, and by category, such as drug information.

It’s a good site to mark and keep handy. I have.

Confidentiality for a celebrity’s health records

April 20, 2008  |  General  |  3 Comments

All of us have the expectation that our medical records, those personal things about us and our families, are safe from prying eyes. Federal law (HIPAA) protects our privacy and mandates quite strict standards, leading to all those forms you have to sign when you go to the doctor. In these days of the electronic medical record, how safe are those records? As I type this I could, if I so chose, call up on my computer the personal details of every single patient in the hospital. What’s to keep me from doing that? Not much, it turns out, other than my own conscience.

A recent story in the Los Angeles Times, discussed in detail on Dr. Bob Wachter‘s excellent blog, shows that, for many people, the temptation to snoop was too much: when Britney Spears was recently in the UCLA hospital, a total of 53 hospital staffers inappropriately looked at her record, 14 of them physicians. Perhaps the bigger scandal is how the miscreants (and all of them knew they were violating both HIPAA and UCLA policy) were treated: none of the doctors were fired, half the nonphysicians were sacked, raising the question of equal treatment for the same crime.

This is not a new problem, of course. I spent much of my career at the Mayo Clinic, an institution well-known for decades for its famous patients, and where the charts of those people were kept well protected. Of course it is relatively easy to guard a physical record, a folder of paper; the electronic medical record is a different matter. Although I am all in favor of the electronic version, this case tells us we must take great pains to secure the data. The case also suggests we don’t treat doctors and nurses the same, and as Dr. Wachter says, that’s not right.

Confidentiality for a celebrity's health records

April 20, 2008  |  General  |  3 Comments

All of us have the expectation that our medical records, those personal things about us and our families, are safe from prying eyes. Federal law (HIPAA) protects our privacy and mandates quite strict standards, leading to all those forms you have to sign when you go to the doctor. In these days of the electronic medical record, how safe are those records? As I type this I could, if I so chose, call up on my computer the personal details of every single patient in the hospital. What’s to keep me from doing that? Not much, it turns out, other than my own conscience.

A recent story in the Los Angeles Times, discussed in detail on Dr. Bob Wachter’s excellent blog, shows that, for many people, the temptation to snoop was too much: when Britney Spears was recently in the UCLA hospital, a total of 53 hospital staffers inappropriately looked at her record, 14 of them physicians. Perhaps the bigger scandal is how the miscreants (and all of them knew they were violating both HIPAA and UCLA policy) were treated: none of the doctors were fired, half the nonphysicians were sacked, raising the question of equal treatment for the same crime.

This is not a new problem, of course. I spent much of my career at the Mayo Clinic, an institution well-known for decades for its famous patients, and where the charts of those people were kept well protected. Of course it is relatively easy to guard a physical record, a folder of paper; the electronic medical record is a different matter. Although I am all in favor of the electronic version, this case tells us we must take great pains to secure the data. The case also suggests we don’t treat doctors and nurses the same, and as Dr. Wachter says, that’s not right.