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Physicians

A test is a useful tool, but can lead to ‘premature’ diagnosis

What happened to Alex Halstead demonstrates that sometimes a quick diagnosis isn't always correct.

Alex Halstead’s appendicitis wasn’t diagnosed during an initial ER visit.

It was finals week in December 2009 and Alex Halstead, a 19-year-old undergraduate at the University of Georgia, was doing some late-night studying for an exam the next day when she felt a stinging pain in her lower right abdomen.

The pain was severe, and she was worried that she might have appendicitis.

By midnight, thanks to her roommate, Halstead was at the emergency room of Athens Regional Medical Center. The doctor on duty felt the problem was serious enough to admit her.

“At this point, I’m pretty much keeled over in pain,” recalls Halstead today.

After recording her vital signs and hooking up an IV of painkillers, the doctor gave Halstead what she remembers as a “metal-flavored milkshake.” This was a contrast agent that makes it possible to view abdominal structures –- such as a swollen and inflamed appendix –- using a CT scan.

The CT scan, surprisingly, showed nothing out of the ordinary.

Based on that scan, the doctor ruled out appendicitis. He concluded instead that Halstead had an ovarian cyst, a much less threatening condition. She’d had one before, and women in her family were plagued by endometriosis, which can sometimes cause intense abdominal pain.

As it turned out, the doctor was wrong.

Looking back, the emergency room doctor appears to have made a type of medical error known as “premature closure,” said family practice expert Mark Ebell, a member of the U.S. Preventive Services Task Force and a professor in UGA’s College of Public Health. This type of mistake happens when a doctor reviews the patient’s symptoms and makes an initial diagnosis without adequately considering other possibilities.

In this case, the doctor jumped to a conclusion based on Halstead’s medical history and the CT scan results.

The doctor at Athens Regional sent Halstead home with pain medication and recommended that she contact her gynecologist in the morning. Her alarmed mother rushed to Athens that morning and drove her to the office of gynecologist Frank Lake, who practices in Gainesville at Northeast Georgia Physicians Group, which is affiliated with Northeast Georgia Medical Center (NGMC).

When Halstead described her symptoms to Lake, he said it sounded like “textbook appendicitis.” He didn’t put much stock in the CT scan, because such tests inevitably miss a certain percentage of appendicitis cases.

“The mistake that can be made is that we rely too much on our diagnostics,” said Lake.

Lake immediately called a colleague at NGMC for a surgical consultation. When Halstead arrived at the hospital, it didn’t take long for the surgeon to identify the cause of her pain.

YouTube Preview Image“He hit the bottom of my heel, and I started immediately vomiting and crying,” Halstead remembers. What she had was appendicitis, just as she had initially feared, and she was rushed into surgery.

Even a slight jolt can cause someone with acute appendicitis to vomit. Knowing that, the surgeon had used a simple physical maneuver –- not fancy equipment –- to identify a potentially life-threatening problem.

In this instance, one doctor’s educated guess and another’s basic exam technique yielded a better diagnosis than did a complex test. But in fairness, Lake readily acknowledges that he and the surgeon may have benefited from the passage of time in Halstead’s case. When they saw the young student, her condition was surely much worse and more obvious than when she was examined in the emergency room.

 

Thinking is a subtle thing

 

Many hospitals now use checklists and other protocols to prevent “procedural” errors, the kinds of mix-ups that can potentially cause a patient to get the wrong medicine or the wrong surgery. But systematic efforts to reduce errors in judgment –- such as misdiagnosing Halstead’s appendicitis –- have lagged behind, said Dr. Scott Richardson, campus associate dean for curriculum at the GRU-UGA Medical Partnership in Athens.

Diagnosis happens in the mind of the physician, not in a public, documented setting. This complicates the challenge of developing regulations or policies that prevent errors. But Richardson sees two areas that policy shifts can target.

The first is noise.

Emergency rooms and intensive care units are often noisy places, making it difficult for doctors to detect subtle clinical symptoms. For example, a quiet but dangerous heart murmur can be drowned out by the cacophonous environment of the ER.

Last November, CBS News reported that a hospital in the Canadian province of Ontario tackled noise pollution by installing sound-absorbing ceiling tiles, creating more private rooms and moving overhead loudspeakers to the hallways instead of over patients’ beds.

Richardson also believes the reimbursement system needs an overhaul.

Sometimes a doctor cannot make an accurate diagnosis after the first meeting with a patient. But under the current system, doctors can be reimbursed only for time and procedures linked to a specific billing code, which reflects a diagnosis. This puts pressure on physicians to label a condition before they really know what it is, Richardson said.

“Some label has to be applied,” said Richardson. “That label develops a kind of momentum, a life of its own, and that tends to narrow further thought.”

In the same way, relying solely on imperfect technology, as the initial doctor did in Halstead’s case, can prevent physicians from using their clinical skills and common sense to figure out what’s troubling their patients.

“If it walks like a duck, and it quacks like a duck, it’s probably a duck,” said Lake.

Nearly 7 percent of people are afflicted with appendicitis at some point in their lives, and the ailment is misdiagnosed between 20 percent and 40 percent of the time, according to the Agency for Healthcare Research and Quality.

 

Ian Branam is a second-year master’s student in health and medical journalism at the University of Georgia. He is interested in developing health and medical content for the web and spent the summer developing a social media campaign for smoke-free workplaces. He particularly enjoys writing about health policy, health disparities and chronic diseases. Follow him on twitter at @ianbranam or visit his website at www.ianbranam.com.

Wearing two hats (or two white coats): The rise of researcher-doctors

Sam Dolezal is is one of five future doctors who are also doing Ph.D. research at the University of Georgia.

Sam Dolezal is one of five future doctors who are also doing Ph.D. research at UGA.

Moving new discoveries from the science lab to the doctor’s office can take decades and cost hundreds of millions of dollars. And although it is not possible to eliminate this process, people who straddle the worlds of science and medicine may be able to speed it up.

Consider the task of translating laboratory findings about a deadly cancer into a simple blood test.

Right now, no such test exists for pancreatic cancer, and by the time most cases are detected, it’s too late for effective treatment. As a result, about three-quarters of pancreatic cancer patients die within a year.

Sam Dolezal wants to change this. Dolezal is an M.D.–Ph.D. student who has already spent two years in medical school. When he finishes his doctoral work three years from now, he will have the credentials of both a physician and a lab scientist. Although the number of physician-scientists is growing, only about 500 people in the United States graduate with both degrees each year.

As their ranks increase, so does the potential for speeding the development of better tests and treatments.

People with both degrees “tend to be very focused on what it’s going to take to get from the [lab] bench to the bed,” said Margaret Wagner Dahl, who heads the Georgia BioBusiness Center and helps University of Georgia scientists turn new findings into products.

Physician-scientists, she says, “have had the training to be able to go through that whole continuum.”

Dolezal is one of five future doctors who are also doing Ph.D. research at the University of Georgia. As Athens’ new medical school campus – the Georgia Regents University-University of Georgia (GRU-UGA) medical partnership – enters its fourth year of operation, possibilities exist for more dual-degree students.

They’ve embarked on a long journey, not only in terms of their own education but also their contributions to patient-ready tests and treatments. A new drug, for example, requires about 10 to 15 years to move from lab to doctor’s office. A diagnostic test, like the one Dolezal is working on, takes around three to five years.

Dolezal works in a spacious lab on the top floor of the Complex Carbohydrate Research Center, a brick and wood building nestled among trees like a mountain lodge.

There, he’s part of a team searching for a cancer marker, a molecule that when found in the bloodstream alerts doctors that pancreatic cancer is present.

The lab where Dolezal works is led by Michael Pierce, a professor of biochemistry and molecular biology who directs the UGA Cancer Center. If the researchers can identify such a marker, the next step will be developing a blood test that can be licensed to a pharmaceutical or biotechnology company. After experiments to confirm its accuracy and safety, such a test could enable doctors to diagnose pancreatic cancer at a point when treatment will be more effective.

YouTube Preview ImageDolezal’s research is shaped by his experiences during medical school. He completed his first two years of med school at GRU’s Medical College of Georgia in Augusta, the parent of the new medical campus in Athens. During his first year, Dolezal met a woman with the type of cancer he now studies in the lab.

“I learned not only how pancreatic cancer was affecting her physically, but also how it was affecting her mentally and emotionally,” Dolezal said. The woman’s only wish was to live six more weeks so she could attend her son’s high school graduation. She met that goal, Dolezal later learned, but died a few weeks later.

“When I’m in the lab, that makes me lean my questions more towards what’s important” for patients, Dolezal said. “Pancreatic cancer doesn’t have a [currently recognized] detection marker, so my project involves trying to find these detection markers.”

While a basic science researcher focuses closely on the biology of the disease, Dolezal’s approach is different.

“He’s looking at it really as a clinician would,” Pierce said. “I can tell he always has in the back of his mind how he can develop his discovery into a treatment or a diagnostic blood test.”

 

The human factor

 

In a lab less than two miles away, Joseph Burch is completing the research portion of his two degrees under UGA microbiologist Harry Dailey. He’s also using his two years of medical training to think about how his research could affect patients.

Burch is studying a protein involved the making of heme – an essential part of the oxygen-carrying blood protein hemoglobin. If the protein is defective, toxic levels of chemicals build up in the body and cause one of several diseases commonly known as porphyria. These diseases can cause patients a variety of problems – from seizures to abdominal pain.

“He’s interested in the bigger picture: How this is going to translate into clinical medicine,” Dailey said.

Currently in his second year of doctoral study, Burch is already thinking how what he’s learned in the lab could help design a treatment for porphyria.

After graduation, students like Dolezal and Burch hope to be able to see human maladies from two different perspectives, and to turn laboratory work into relief of human suffering.

“If you got just a Ph.D. and you do biomedical research, you can work in a lab, you can work on animals, but you can’t work on people,” Dailey said. “With a Ph.D. and an M.D., it allows you to do the basic work and to translate it into the clinics.”

Burch is optimistic about his broad education.

“I hope it will make the transition from lab research to drug discovery or treatments more efficient and faster.”

 

Julianne Wyrick is a freelance science and health writer currently completing the health and medical journalism graduate program at the University of Georgia.

Mistakes are every doctor’s nightmare, but what to do about them?

Dr. Howard Cohen spent nearly 30 years as an infectious disease physician in Atlanta.

He treated people with everything from the flu to malaria.

He was a highly respected doctor, recognized in his field. But about a decade ago, Cohen made a mistake that he has never forgotten. And he doesn’t want to forget.

At the time it happened, he was far from a rookie. He was a seasoned professional at the top of his game.

As Atul Gawande — a Boston surgeon and bestselling author — put forth in a 1999 article in the New Yorker magazine, “When Doctors Make Mistakes,” many medical mistakes are made by good, highly regarded doctors, not by the habitually negligent.

And critical mistakes occur often. A recent study in the Journal of Patient Safety said that  210,000 to 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death.

YouTube Preview ImageCohen’s mistake was simply a mix-up, but a troubling one. It all started when two of his patients, whom he calls A. Jones and B. Jones, visited his private practice office at about the same time.

The two women had the same last name, but different first names and very different prognoses.

A. Jones was a patient of Cohen’s with a known blood abnormality, and Cohen ordered laboratory tests to determine whether her condition had worsened.

B. Jones, on the other hand, was a healthy woman who had come in for a periodic check-up. Cohen found nothing out of the ordinary during an examination, but as matter of routine, he had a sample of her blood drawn and sent to a lab for testing.

In the rush of a busy practice, mix-ups can happen.

Numerous lab reports arrived at the office every day and were stuffed into patients’ charts, where doctors read them and acted on them. In the hurried atmosphere, most doctors never questioned whether a particular lab report was in the right folder.

When Cohen looked at the test results in B. Jones’ folder, they showed significant abnormalities suggesting leukemia, even though she had seemed healthy a few days earlier. He immediately reached out to her and asked her to come in for a face-to-face consultation.

B. Jones came in the next day and got the totally unexpected news that she appeared to have a serious illness.

“I feel fine,” she said, but she was also stunned and frightened.

But then her gaze focused on the chart in Cohen’s hand, and she saw that something was amiss on the lab paperwork. The birth date was not hers.

As it happened, the worrisome test result actually belonged to A. Jones, the patient with a history of blood abnormalities. The result had mistakenly been put into B. Jones’ folder.

A wave of relief swept over B. Jones as she realized she was healthy after all and that her doctor had mistaken her for another patient. Cohen was quick to apologize for the blunder.

“I said, ‘I’m so sorry. I’m so sorry I made you feel so stressed for 24 hours,’ ” Cohen recalls. “I said we made a mistake.”

Within 24 hours, Cohen notified A. Jones of her test result. It signaled a turn for the worse in her condition. But given her previous problems, she was disturbed by the news but not overwhelmed by it.

 

Apologizing may go a long way

Cohen felt horrible for the false alarm he had given B. Jones.

“For a night there, I’m sure this lady didn’t sleep,” he says today.

To his surprise, the woman was so relieved when she was told about the mix-up that she gave him a big hug.

This is not as surprising as it seems. A 2010 study from researchers at the University of Michigan and Brigham and Women’s Hospital showed that when doctors apologize for their mistakes, it can actually prevent malpractice lawsuits.

In fact, there are entire organizations devoted to this philosophy.

Sorry Works! Consulting, a company in Glen Carbon, Ill., provides training and resources to health care professionals to teach them to disclose when they have committed an error and apologize to patients and their families.

The company was started in 2005 by consultant Doug Wojcieszak. He had lost a brother to medical errors in 1998, and his goal was to reduce malpractice lawsuits as well as medical errors.

“It’s often not bad individuals, it’s poor systems that get in the way,” says Dr. Scott Richardson, campus associate dean for curriculum at the GRU-UGA Medical Partnership in Athens.

Richardson mentions systems redesign, an approach to health care championed by the Agency for Healthcare Research and Quality (AHRQ), as an important factor in reducing medical errors.

It includes mechanisms like electronic health records and checklists to limit the potential for human error. This strategy has been used to reduce medication errors, delays in performing surgery, and paperwork mix-ups like Cohen’s, says Richardson.

In the New Yorker piece, Gawande described an error he made as a surgical resident in an emergency room. A car crash victim came into the ER with a blockage in her airway, and after Gawande and his medical team made repeated attempts at intubating her, she was no closer to breathing on her own.

She needed a tracheotomy to have the breathing tube inserted through her windpipe rather than orally.

Gawande, who blamed himself for the mistake, said he should have been preparing the patient for a tracheotomy, and instead let the emergency medicine attending physician continue attempting to intubate the patient.

This made her vocal cords swell, and her airway shut down. Eventually, the intubation was successful, but the long period of time she went without oxygen made it unclear how much brain function she would have when she regained consciousness.

In August 2012, Cohen put down his stethoscope to become a full-time medical school professor in Athens at the GRU-UGA Medical Partnership.

Immediately after the mix-up in his office a few years ago, he met with the office manager and the staff to go over their policy for handling abnormal test results and verifying information before calling patients. A clearly defined procedure for notifying patients of lab results can prevent patients from being alarmed unnecessarily.

And ever since that day, says Cohen, he has been more careful himself. He always double-checks in any situation where an error might occur.

He believes that electronic health records — which are increasingly being used in the United States and will become even more widespread under the Affordable Care Act — will reduce the likelihood of medical mistakes. But they will not eliminate them completely.

There is still the human factor.

“Computers may be infallible, but the data put into the computer may not be,” he says.

 

Ian Branam is a second-year master’s student in health and medical journalism at the University of Georgia. He is interested in developing health and medical content for the web and spent the summer developing a social media campaign for smoke-free workplaces. He particularly enjoys writing about health policy, health disparities and chronic diseases. Follow him on twitter at @ianbranam or visit his website at www.ianbranam.com.

 

Who likes the ACA? Top Medicare official says law is boon for seniors

Recent problems with the Affordable Care Act — a poorly functioning insurance exchange website and an uproar over canceled policies — have dominated headlines and reignited political debates.

But Jonathan Blum has a positive message to deliver about the ACA and its effect on the Medicare program, which covers about 1.4 million Georgians.

Jonathan Blum

Jonathan Blum

Blum, principal deputy administrator for the Centers for Medicare and Medicaid Services, says the 2010 health care law has led to better quality of care and more benefits for seniors while containing the costs of the federal program.

GHN recently interviewed Blum about the ACA’s benefits changes, hospital readmission penalties, accountable care organizations, and Medicare Advantage growth, along with medical education funding and possible scams that seniors should avoid.

Q: We’re right in the middle of open enrollment for Medicare beneficiaries. What are your main messages for seniors?

A: The Medicare program is stronger today than in recent memory. The Affordable Care Act has [given] the program more generous benefits, and quality of care is improving by various measurements. And at same time, costs remain very manageable.

There used to be the notion that there was a tradeoff between more benefits and higher quality and costs. What we are seeing in Medicare is growing evidence that we can add more benefits and increase the quality of care while keeping cost growth very manageable.

Medicare Part B premiums for 2014 are going to be the same amount as 2013, primarily due to lower-than-expected cost growth. With the Affordable Care Act’s framework for quality improvements, and to add preventive benefits, we’re seeing growing signs that the strategy is working both for beneficiaries and also for taxpayers who fund the program.

Q: Talk about these new benefits.

A: The two main categories of benefits really change the emphasis of the program. The first is free cost-sharing [i.e., no co-payments] for preventive benefits. Medicare beneficiaries for the first time have the opportunity to have an annual wellness visit with a physician. Screenings like colonoscopies and recommended preventive care have free cost-sharing.

For those who have the drug benefit, the coverage gap is now being narrowed. There is growing evidence that beneficiaries are complying with their drug regimens. Their drug regimens are coordinated with their overall care. They avoid hospital stays and other significant health care events.

The free preventive benefits, and the part D benefit becoming more complete, [constitute] a change in emphasis in how Medicare is oriented — from being a program that only pays for people when they’re sick [to] a program that [also] is keeping beneficiaries healthy for a longer period of time.

Q: When Medicare Advantage was first started, there was a lot of pushback against it. Now these private health plans serving Medicare patients have becoming increasingly popular.

A: I think if you followed the debate on the Affordable Care Act, the notion was the president’s proposal and the act’s ultimate policies to reduce payments for the [private] plans would decimate the program.

Quite the opposite has occurred. We’re at an all-time high in beneficiaries — in [raw] numbers and percent — who have chosen private plans to receive their Medicare benefits. Premiums have fallen on average since the Affordable Care Act. We’ve seen no signs on average that plans have reduced their benefit offerings. The quality of the plans has significantly changed for the better.

Q: This is an example of more pay for better performance by providers?

A: Before the act, we had about 16 percent of beneficiaries with a private plan choose a 4-Star or 5- Star [rated] plan. Today, for 2014, more than half of beneficiaries who have chosen a private plan are in a 4-Star or 5-Star plan.

Q: What percentage of Medicare recipients are in Advantage plans?

A: It’s close to 30 percent. Before the Affordable Care Act, it was about 21 or 22 percent.

Q: And the plans are getting less money for serving patients?

A: As a share of the fee-for-service program. Prior to the Affordable Care Act, on average, the plans were receiving 13 percent to 14 percent more than the fee-for-service program [for a total of 113 percent to 114 percent]. Now it’s down to 103 percent, 104 percent. It’s going to continue to phase down.

The plans on average are being paid less, they’re still offering competitive benefits. Premiums are lower on average than before the act was passed. It’s part of our key strategy to achieve our quality-of-care goals. It’s really pleasing to us that so many more beneficiaries who have chosen a private plan are in a 4-Star or 5-Star-rated plan.

Q: Many seniors are confused about whether to sign up for an exchange, as part of the ACA.

A: The key message for Medicare beneficiaries is the exchanges are not part of the Medicare system.

The Medicare system will operate the same way it has always operated. Medicare beneficiaries should go to their same sources of information — medicare.gov or 1-800-MEDICARE.

They will receive their benefits the same way. They don’t have to apply for anything through the exchanges. If you receive Medicare benefits, you don’t need to think about the exchanges.
Medicare beneficiaries should not fall for any scams or false information about signing up for a plan in the health insurance marketplace.

What the Affordable Care Act has done is . . . [add] benefits and . . . [elevate] the overall quality of care.

Q: Talk about the effectiveness of the penalties for hospitals that have too many readmissions [of discharged patients].

A: We have put in place payment penalties for hospitals that have higher-than-expected readmission rates. The readmission rate for the past year and a half, for the first time in [the] five years the agency has tracked it, is falling. It’s about a percentage point lower than it was the previous five years.

What that means is about 70,000 fewer hospital readmissions are paid for by the Medicare program on a monthly basis. That’s a real impact for beneficiaries. My dad was in the hospital last year. His care was not well coordinated and he had a hospital readmission — a classic case. It was very traumatic for him and for our family. Everybody was very worried.

It’s tangible, meaningful changes in the health care system.

Q: Is it improving nursing home care?

A: What the readmission [rule] has done is force hospitals and nursing homes to have better systems of coordination. It used to be the incentive for nursing homes was to send the patient back to the hospital. So Saturday night, if the patient had an issue, the automatic response was to send the patient back to the hospital. Very traumatic for the patient and the family.

These pay-for-performance systems are changing behavior and building stronger relationships, so beneficiaries have more care coordination, there are not just single episodes of care or silos of care.

Q: Seniors often talk about the lack of dental care in Medicare.

A: Well, really it’s an artifact of the statute when it was created; it’s not something that we do purposely. Some managed care plans that participate in the Medicare program offer dental coverage as a supplemental benefit.

There are some gaps in the Medicare benefit package. Lack of coverage for hearing aids, that’s a statutory prohibition. Dental care, the same thing. Some managed care plans offer them as supplemental benefits.

President Lyndon Johnson signing the Medicare law with former President Truman looking on.

President Lyndon Johnson signing  Medicare legislation with former President Truman (right) looking on.

Q: Is that something that could be changed, that could lead to better health?

A: There’s good research that good dental health is a key factor in good overall health. Our limitation is that we’re bound to the statute.

Q: Evaluate the progress of Accountable Care Organizations [combinations of doctors, hospitals and/or insurers created to lower costs and improve quality of care].

A: One of the changes in the Affordable Care Act was to bring about organizations that acted like systems of care rather than silos of care. I would describe it as groups of physicians who are coming together and promising to be accountable for a population of Medicare beneficiaries.

It’s a notion that team-based care is better than individual care. Care is coordinated across different office and hospital settings. With care coordination, duplication of lab tests and other tests would be reduced.

We’ve been overwhelmed . . . [at] the response by the physician community in participation. We have more ACOs today operating in the Medicare program than we anticipated.

It doesn’t change how beneficiaries interact with the health care system. It doesn’t change how we pay physicians on a service-by-service basis.

At the end of the year, ACOs can demonstrate they met the quality benchmark and they can demonstrate that overall total health care costs have been reduced, and the organization can share in the savings.

Q: How many beneficiaries are being served by ACOs?

A: We estimate that about 4 million beneficiaries are being served by ACOs across the country.

Q: Are they saving money?

A: It’s too early to state with certainty whether the program has saved money [for the taxpayer]. But to me, if we are paying the same and the quality of care has improved, that’s a huge win.

Q: Where do you see the ACO trend going?

A: I see the share of Medicare-participating physicians and Medicare beneficiaries served by ACOs continuing to grow. Clearly the Congress is very interested in trying to . . . [encourage] more physicians to participate with ACOs.

Beneficiaries seem to understand this model, seem to understand that it works for their care. We notify beneficiaries that their doctor is participating in an ACO, and they have the opportunity to opt out.

Q: How will they see their care is different?

A: Their care will be coordinated. When they go to the hospital, their physician will know that. Senior groups tell these stories — that one doctor orders a blood test, then another one orders the same test. Why can’t their doctors talk to each other?

Our expectation is that patients will have more time with their doctors rather than less.

We had assumed that beneficiaries would complain and choose to opt out of the data-sharing. Very little of that complaining and opting out of that data-sharing has gone on.

Q: Are you concerned about doctors dropping out of Medicare?

A: No. Those physicians who have dropped out are a very small share of physicians and tend to be those physicians who don’t treat Medicare patients. I think there are some pockets across the country that we have to be mindful of. Some of those [news] stories that came out this summer were not using accurate data.

Q: An article recently described how Medicare isn’t paying uniformly for physician education across the country.

A: There’s been a long history in the law for how payments are sent to teaching hospitals. This is another example in the Medicare program where history matters, and that has created differences across the country, where we’re paying a lot more, say in New York City, than [some other places] across the country.

It’s not a policy choice, it’s an artifact of the statute, how the system has been created to establish these payments.

Right now it’s true that Medicare doesn’t necessarily set standards for graduate medical education for the funds paid across the country. That’s a growing policy trend to watch. A question I hear more and more is, ‘Should the Medicare program demand more accountability for the significant share of graduate medical education that it’s funding?’ It’s a question that the Congress will have to ultimately answer.

Q: Anything you want to add?

A: It’s a hard message right now obviously to convey, with everything going on with the exchanges, but I do think one of the really good news stories of the Affordable Care Act is the impact on costs and quality, as primarily seen through the Medicare program.

Some say the Affordable Care Act didn’t do anything to reduce costs. Well, yes it did.

Look at the Medicare program now. It’s the biggest health care program in the country. Quality of care has increased. Benefits have been added. I believe it is possible to add benefits and improve quality while lowering costs. The past three years we have demonstrated that it’s possible in the Medicare program.

What do med students learn in the ER? Valuable lessons indeed

Dr. Sam Kini teaches emergency medicine to fourth-year med students in Athens.

Dr. Sam Kini (right) teaches emergency medicine to fourth-year med students in Athens.

Emergency medicine is unique.

At any time of the day or night, practitioners in an ER must be ready to treat any kind of problem, said Dr. Sam Kini, a veteran emergency physician. Patients rush in with everything from chest pains to vaginal discharge. Among the common problems are back pains, abdominal cramps, fevers, bruises and sprains.

Kini, who now teaches and supervises fourth-year medical students at the Georgia Regents University-University of Georgia Medical Partnership in Athens, said the ER is a blend of specialties, and that makes it an invaluable place to teach.

“We see patients with all kinds of complaints, and we want the students to have that experience of just seeing all patients, all types, all ages, all hours of the day and night,” he said.

In 2010, Medicaid patients made up the majority of ER visits in Georgia, according to state data. The American College of Emergency Physicians (ACEP) said it expects ER visits to increase nationwide as the Affordable Care Act triggers Medicaid expansion in a number of states. (About half the states, including Georgia, have opted not to pursue expansion.)

“Increasing the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the flood of patients into our nation’s ERs,” former ACEP board President David Seaberg said in a statement.

Emergency medicine has grown in popularity among graduating medical students. Data from the Association of American Medical Colleges showed that the average of emergency medicine residency applications increased from 28 percent in 2010 to 31 percent in 2011. In 2012, the number increased to 35 percent.

Yet Kini said that only five of his 40 students plan to complete an emergency medicine residency after graduating in 2014.

Georgia was reported to have a shortage of emergency physicians in 2008. As of 2012, the state had an estimated 1,110 emergency doctors, while Michigan, a state with a similar population, had twice that number, according to Kaiser Family Foundation data.

During their fourth and final year of medical school, students have three required, month-long clerkships, also called rotations, to complete in addition to three electives and a sub-internship. Students spend one day each week in the classroom and up to four days at hospitals throughout northeast Georgia.

The emergency medicine rotation will be valuable to students regardless of what specialty they choose or where they practice. An emergency can happen anywhere,
including in a routine medical setting such as a physician’s office or an orthopedic clinic. When patients experience frightening symptoms — such as chest
pain or sudden numbness — they expect physicians to know how to react.

Fourth-year medical student Bree Berry completed her emergency medicine rotation at Eastside Medical Center in Snellville. She was barely into her second week there when she had an unexpected but unforgettable experience.

“On Labor Day I saw a guy who had an accident with his table saw and nearly amputated [all] five of his fingers on his right hand,” Berry said.

Berry plans to go into primary care, so she probably won’t see such severely injured patients often, but she recognizes how the rotation will be useful to her.

“Since I don’t plan to be working in an emergency room, I think it will be valuable for me to know which patients I need to send to the emergency room,” Berry said, “and which I can safely treat in my office.”

Surprises can teach good lessons

Some patients who come into an ER have valid emergencies, while others misuse the ER as a replacement for primary care. This is one reason why emergency physicians never really know what to expect from the unscheduled patients who come through their door.

YouTube Preview ImageThis element of surprise may be frightening for some medical students, but for Xiao Li it was exciting and helped him grow as a physician. He said he enjoyed knowing only a name and an age when first entering a patient’s room.

“When it comes to emergency medicine, what I like most about it is that you never know who or what’s coming in,” said Li, who completed his clerkship at St. Mary’s Hospital in Athens and plans to specialize in radiology.

At least once a week, Kini visits his students at their rotation site to note their progress and assist ER physicians with teaching. He and the ER physicians teach students to recognize common and serious diseases and order the appropriate tests. Students also learn how to determine the correct treatment and decide which patients need to be admitted to the hospital and which can go home.

When Kini works with a student in the ER, he lets the student take the medical history and perform a physical examination first while he asks the student questions about the procedure.

Once the student has completed these tasks, Kini will perform the same tasks on his own, while the student notes the differences in the way Kini handled the patient. Afterward, the two go outside the patient’s room to exchange thoughts and notes privately.

Kini said playing the role of both student and instructor helps students appreciate what they did right as well as understand what they should have done differently. He said when students recognize why he asked certain questions that they did not, they are able to learn from their mistakes.

“It gets the student to think, as to why I asked this question [and] why they missed it,” Kini said, “and they won’t miss it in the next room.”

 

April Bailey is pursuing a master’s degree in health and medical journalism at the University of Georgia. She currently holds a bachelor’s degree in print journalism from Middle Tennessee State University.

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