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JC Physician blog – News for M.D.s from M.D.s at The Joint Commission

Written by and for physicians, the biweekly JC Physician blog discusses health care issues of interest to doctors as well as other topics that may touch on ethics, the environment and current affairs.

NOTE: Physician are encouraged to submit guest blogs for the JC Physician blog. Those interested should contact Social Media Specialist Sean Ostruszka.
 

 

The Tragedy of Physician Suicide


Oct 08, 2014 | Comments (0) | 1315 Views

By Paul Ziaya, M.D.
Field Director
The Joint Commission

It was an alarming read, to say the least.

In early September, an op-ed by Dr. Pranay Sinha, titled “Why Do Doctors Commit Suicide?,” appeared in The New York Times. The author spoke to the tragedy that is suicide, specifically about new physicians as they negotiate the difficulties of residency education. The statistics alone were worth the read – nearly 10 percent of fourth-year medical students and first-year residents reported having suicidal thoughts in the prior two weeks.

Residency is a very stressful time. We all remember that.

So despite the nationally implemented reduction in weekly hours for residents and programs implemented to assist with coping, suicide remains a risk. For physicians in general, there may be as many as 400 completed physician suicides each year in the United States. This is a worldwide issue and, as Dr. Louise Andrew noted in her Medscape article, “Physician Suicide,” “Depression is at least as common in the medical profession as in the general population, affecting an estimated 12 percent of males and 18 percent of females. Depression is even more common in medical students and residents, with 15-30 percent of them screening positive for depressive symptoms.”

The factors that may lead to suicide are many and, perhaps related to physician knowledge of and access to medications, physicians have a higher rate of completing an attempted suicide than in the general population.

Depression is difficult enough to recognize in others, but even when physicians recognize depressive symptoms in themselves, the majority fail to seek help; why is a complicated question. Perhaps it’s due to concerns about the potential effect on their careers or the sense that they are supposed to be the healers, not those needing healing.

Joint Commission standard MS.11.01.01 is specifically written to encourage medical staffs to identify and manage matters of individual health in ourselves and our colleagues. Separate from actions taken for disciplinary purposes, it focuses on education of physicians to recognize issues in others and also encourages self-referral in an effort to result in confidential diagnosis, treatment and rehabilitation to “retain and to regain optimal professional functioning that is consistent with protection of patients.”

Physicians, despite all their knowledge, are like everyone else in their risk for depression and suicide. Yet they have trouble getting effective treatment. While resources exist to help, we must continue to remove the stigma and other barriers associated with getting the needed assistance. That perceived stigma is thought of as a dangerous thing to a career or a physician, but we all must remember it pales in comparison to the depression itself.

Yes, The New York Times piece was alarming. Hopefully it’s an alarming reminder that despite efforts over more than a decade to recognize and improve the factors that may affect the rate of suicide in physicians, there still remains much to be done, and we as medical staff leaders and colleagues have an important role to play.

Doing No Harm


Sep 10, 2014 | Comments (1) | 1357 Views

By Paul M. Schyve, M.D.
Senior Advisor
The Joint Commission

Paul M. Schyve, M.D.Primum non nocere – Not many of us remember Latin phrases, but all physicians recognize this one: First, do no harm.

That motto has been one of the principal ethical obligations of physicians ever since it was declared by Hippocrates, the father of Western medicine. Of course, over the years we have clarified its meaning in light of modern medicine. The pain associated with surgery and physical therapy, the unavoidable side effects of pharmaceutical agents, and the unpredictable adverse events in health care have led us to say “first, do no preventable harm,” to discuss with our patients the potential risks and side effects of treatment, and to disclose to our patients unanticipated outcomes of care.

But despite these modifications, the basic ethical obligation stands: First, do no harm. For many years, physicians were taught – and believe – that meeting this obligation was focused on our own individual patients, that is, in our patient-by-patient relationships. In order to do no harm to each of our own patients, we needed to be competent in our cognitive and motor skills, and committed to our professional obligations to our patients. We assumed that competence and commitment were sufficient to avoid harm. Nevertheless, as much as we strive to be competent and committed, bad things still happen to our patients.

During the past 15 years, as we at The Joint Commission have studied adverse events, we have recognized that many more preventable adverse events occur than we had thought. It has become clear that most adverse events have not occurred because an individual physician (or nurse, or pharmacist) has insufficient competence or commitment, but because of failures in teamwork and in the systems and processes within which we work. Even when the adverse event resulted from an individual’s error, we have learned that an improvement in teamwork or a redesign of the system or process would have helped prevent the error from reoccurring – it can protect the individual from the “normal, inevitable” human errors that we all make.

All of that means if physicians want to fulfill their ethical obligations to their patients to do no harm, they must invest not only in their own professional competence and commitment, but also in the function of their clinical teams and in the design and operation of the systems and processes in which the teams operate. This investment requires more than the participation in the peer review contemplated by the Joint Commission Medical Staff hospital standards for the credentialing and privileging processes – a peer review that traditionally focused on the individual physician’s competence and commitment. This investment also requires participation in, and often leadership of, quality and safety improvement programs and processes, as contemplated by the Joint Commission Medical Staff and Leadership hospital standards.

Physicians’ ethical obligation to do no harm has not changed over the centuries, but the methods to fulfill this obligation have changed in recent years.  While physicians’ investment in teamwork and in system and process improvement adds to their work, it is a critical and necessary contribution to success in meeting their ethical obligation. As health care adapts, primum non nocere is still a strong thing to remember
 

Teach a Patient to Fish - Part 1 of a series on patient engagement


Sep 03, 2014 | Comments (0) | 1546 Views

Ronald Wyatt, Medical Director, The Joint CommissionRonald M. Wyatt, M.D., M.H.A.
Medical Director
The Joint Commission

There’s a famous saying about the difference between giving a man a fish and teaching him to fish. I’m going to adapt it.

Ask a patient a question, you get a conversation. Teach a patient to get involved in his health care, you get a partnership.

Partnerships, be it patients and health care professionals or policymakers and government agencies, are essential. Even Avedis Donabedian – the originator of the measurement triad of structure, process and outcomes for evaluating clinical quality – proposed a patient-centric definition in 1966 in which the patient’s involvement “is the ultimate validator of the quality of care.”

There is growing awareness that to achieve the best outcomes, patients and families must be more actively engaged in decisions about their health care. Patient engagement is a precursor to patient activation and a necessary first step to maximizing a patient’s role in their health care.

A patient’s level of activation is inextricably intertwined with patient safety. Activated patients are more likely to avoid medical errors and unnecessary hospital readmissions. In its report entitled “Beyond 50.09 Chronic Care: A Call to Action for Health Reform”, American Association of Retired Persons noted that lower patient engagement is significantly associated with experiencing a medical error and more problems in the health care system, which suggests that health care organizations need to assess and enhance a patient’s level of activation. Less activated patients suffer poorer health outcomes, a higher medical error rate, are less likely to look out for themselves and are less likely to follow their provider’s advice than the most activated patients. The report found that patients’ involvement in their health care is likely to reduce errors, adverse events and nonadherence to treatment.

So, knowing the importance of teaching patients to get involved brings up the next question: How do we do it?

You’ll find the answer in Part 2 of this series, where we will discuss the roles of leadership and staff in this process. And Part 3 will delve deeper into additional, targeted approaches to increasing patient engagement and activation.

 

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Fighting costly and complex … with your help


Aug 20, 2014 | Comments (0) | 813 Views

Daniel J. Castillo, M.D., M.B.A.By Daniel J. Castillo, M.D., M.B.A.
Medical Director
The Joint Commission

You got a taste four months ago. Now, it’s time for the first course.

Back in April, I wrote a blog mentioning an upcoming article I was writing for The Journal of Integrated Healthcare Delivery. I’m happy to say that article, Developing a Strategy for Change, published July 1.

If I caught your attention in the last blog with the $650 billion figure I quoted related to the cost of U.S. health care spending more than other developed countries, you’ll want to read more in the journal article about how emerging integrated systems are working to address waste, cost and quality. Basically, I have visited and spoken to many organizations that are at varying places in their journey towards a truly integrated system. A common theme is that seamless delivery of care and patient-centered clinical integration are difficult because of the rapidly changing landscape, the uncertainty of reimbursements, and the entrenched provider-centered model that flourished for decades. 

What is clear is the need for change. My article starts spelling out this need, but I look to build on this momentum with additional writings on the topic.

Along those lines, it would be great to hear from those going through this journey towards integration, so that I can learn from you, and we can all learn from each other. Whether you’re planning it, going through it, or have gone through the journey, I ask that you to contact me at dcastillo@jointcommission.org.

The Joint Commission will continue to explore opportunities for the evaluation and inspiration of valuable integration that improves outcomes for patients. I’m hoping we can work together toward this goal.  

Are you a revolutionary?


Aug 06, 2014 | Comments (0) | 1122 Views

Erin DuPree, MDBy Erin DuPree, MD, FACOG

Dr. Ernest Amory Codman believed in studying information about a patient, the care he or she received, and the result of that care. That hardly sounds revolutionary nowadays, but considering when Dr. Codman began his “end results system” – the early 1900s – it was not only revolutionary but also outrageous. 

Dr. Codman was considered a rebel by his peers. He was socially ostracized – even by his friends – and he resigned in disgrace as chairman of the local medical society, all because he firmly believed in the end results system.

Luckily, he never wavered in his beliefs, because it was this work that led Dr. Codman to help found the American College of Surgeons and its hospital standardization program, which was the forerunner of The Joint Commission. 
It’s with this in mind that I was honored to attend, on behalf of The Joint Commission, a dedication service for Dr. Codman on July 22, at the Mount Auburn Cemetery in Cambridge, Massachusetts. He had been buried in an unmarked grave all of these years, and the ceremony rectified that, thanks to the efforts led by Dr. Lamar McGinnis.

Dr. Codman was a true revolutionary, not only with his ideas but his actions. He blazed the way for many of us today that are determined to do what is right for the patient. He pushed for the standardization of care processes. He pushed for detailed systems of patient records, including postdischarge follow-up. He pushed for registries to follow patients nationally. He pushed for the public reporting of hospital and physician performance. He pushed for what today is known as outcomes management. He was 100 years ahead of his time.

We all owe a debt of gratitude to Dr. Codman for his passion and commitment to “end results” – his belief that the key to improving quality is through the thoughtful and careful examination of processes followed, treatment provided, and care administered by health care professionals. And, while his efforts were largely dismissed by the medical community at the time, he never wavered, holding firm in his commitment to making health care safe and effective for all.  He is a legend because of that firm commitment. His dream was for patients to have the essential information they need to make informed choices about their treatment and where to go for care.

In every sense of the word, Dr. Codman was a revolutionary.

Dr. Codman’s amazing legacy gave me pause in my busy week as a physician at The Joint Commission and as a patient. I have a dream of safe, reliable, effective, individualized care for all. We have so far to go, as I witnessed during a routine outpatient appointment today. 

Reflecting on Dr. Codman’s career, and reading a recent piece in The New York Times, I was forced to ponder what it means to be a revolutionary.

That prompted me to ask, "What can I do today?" How can I move through all the barriers and inertia? What are the levers and opportunities at my disposal?

I wonder if Dr. Codman asked himself these questions. He certainly had no shortage of barriers. Yet, he persevered. Here’s hoping more of us are inspired enough to follow in his footsteps toward being revolutionaries.
 

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