12 minute read
Medical/Legal
University of Florida. I went to the University of Washington for an Interventional Pain Medicine Fellowship. From there I joined a private practice in Orlando for several years and I moved up to the Panhandle almost 6 years ago. My original plan was to live in the same place I grew up and make Orlando my permanent home. For several reasons, a topic for a different article, I decided to make a change. My family packed up and we moved to the Panhandle knowing that worst case scenario I would be here for 2 years to serve out my non-compete and then move back to Orlando if I so chose. But something happened, perhaps it was my first Blue Angels Show, but I truly fell in love with the area and the people and in my heart, this became my home. I joined the ECMS right away as a chance to meet people as I am a bit of an introvert by nature unless it is something I am truly passionate about. I stayed because I became inspired. I stayed because perhaps I may have found something that was missing for me, that same camaraderie that I felt as a college athlete, people working together for a common goal.
I began to wonder:
What was the ECMS all about?
How could I get involved?
Could I make a difference?
Surely, I could not, but then, again, why not me?
I listened to those that came before me and continue to serve. I listened to the viewpoints of those that were different than mine and continue to do so. I genuinely believe that the practice of medicine is a privilege. We are privileged to take care of human beings during some of the most vulnerable times in their lives. It is humbling and without a doubt an honor, one of my biggest honors. How can I continue to make a difference? Can I make a difference amidst all of the chaos, especially the chaos of the last 2 years? Never in my wildest dreams did I think I would be helping to lead a practice and serve on the ECMS executive board during a pandemic, certainly not one that lasted two years. No one could have possibly imagined or been prepared. The light in the middle of the storm is that we figured it out together. We figured it out and continue to figure out how to weather the tough times and make decisions in the best interest of our community and patients. The hospital systems worked together and shared information and resources to care for our patients and community. For me, us coming together, that was and is the light in the darkness. Perhaps (fingers crossed) in the not so distant future “the time of COVID” will become a memory and a lesson in the history books. I pray that we never forget all that we have learned throughout this unprecedented time and we still always remember that our goals and passion are common and unite us all. In our organization and in our meetings, you will listen and discover that you have other passions that are similar to those of your colleagues and together you can work to advance medicine for our community, state, and country. In these rooms you will find people that are eager to give back but do not know how and they will connect with colleagues that do know how and are doing so successfully. How we learn and grow is by stopping, listening, and becoming involved.
Thus, my message and mission for this year, is for us to learn to come together in fellowship and truly hear one another. Only then will we be able to effect change, whether it be in your hospital, your practice, your city, your state, or your country. Dream big. Perhaps some of the issues that divide us aren’t black or white or right or wrong. Can you discuss one side of an issue without truly trying to understand the other side? One of my favorite speeches was Dr. Ellen McKnight’s speech about becoming an Activated Physician. How much more powerful would we be if we were not only activated, but we were activated together? Together we march forward. Whether you are just starting out in your career, get involved. Whether you are nearing retirement, get involved. We need your wisdom and guidance. Whether you are hospital employed, private practice, academic or military, Generation A through Z, get involved. We effect change by coming together in fellowship and listening to each other, learning from each other, and becoming inspired by each other. If you heard my inaugural speech, I took a moment to thank my amazing husband, for which none of my accomplishments would be possible, my children, my family, my dear friends, and my colleagues. I shared with each of you in attendance a bit about my village. They say it takes a village to raise a child. I will use the same statement and say that it takes a village, our village to effect change. I thank you for being a part of my village and look forward to seeing you all soon.
– Kacey Montgomery, M.D.
Medicare Changes That Can Save Money for Seniors
by Dennis Mayeaux, M.D. and Maureen Padden, M.D.
Medicare benefits can be a challenge to navigate, and unanticipated bills for services you thought were covered can cause financial strain. This has been an issue with some of the vaccinations currently recommended – while some are covered under Medicare Part B, others are covered under Part D.
This disparity has led to wide variation in deductibles, copayments, and formularies for vaccines recommended to preserve your health. This causes some individuals to forgo crucial vaccinations that could protect their health, while others proceed unaware of this difference until the bill arrives in the mail. Forgoing crucial vaccinations affects our most vulnerable population the most—our seniors.
As physicians, we know firsthand how dangerous that can be for Florida’s elders, whose weakened immune systems make them more susceptible to the worst consequences of infectious diseases.
However, there is a solution to this problem. In Congress, a bill called the Protecting Seniors Through Immunization Act is gaining bipartisan support. This bill would align the rules under Parts B and D and eliminate copays for these lifesaving, recommended vaccinations.
Seniors are already pinching pennies, and simple measures such as this would allow many to obtain the vaccinations crucial to protecting their personal health and the health of their community.
In addition to better protecting our most vulnerable citizens, expanding preventive medicine in this way will also benefit our entire health care system. Allowing greater access to vaccines is cost-effective, helping to keep many people out of the hospital and avoiding the need for costly care. Our experience with COVID-19 over the past two years reinforced that our aging 65+ population is more seriously affected by infection. In fact, according to the Centers for Disease Control and Prevention, 75% of people who have died from the virus in the United States have been 65 or older. That’s a rate of 1 in 100 seniors, compared to 1 in 1,400 individuals younger than 65, dying from a virus that could have been prevented, or at least lessened.
We should all encourage Congress to support the Protecting Seniors Through Immunization Act as it works its way through the system.
This bill would create some much-needed changes to Medicare by increasing the access and affordability of vaccines and, in turn, save lives. Health protection is one issue we can all get behind in 2022.
Dennis Mayeaux, M.D., is a family physician/geriatrician in Milton, FL.
Maureen Padden, M.D. M.P.H., is a family physician in Pensacola, FL.
To Measure and Reduce Diagnostic Error, Start With the Data You Have
David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors
As a patient safety problem, diagnostic error differs from wrong-site surgery or medication errors. While we have not yet eliminated these errors, we know that systems-safety interventions like checklists and time-outs make an impact. But in considering diagnostic errors—when we are often trying to get inside someone’s head to determine why they did or didn’t think a certain thing—it is a totally different proposition.
Moreover, at times, we lack clear distinctions between true diagnostic error and the natural progression of a disease. We know that diagnostic errors occur across specialties and patient populations, but surprisingly, we see that common conditions are often missed. Progress has been made over the past decade, as shown by Hardeep Singh, MD, MPH, during his recent presentation for the Healthcare Risk Advisors (HRA) Virtual Conference Series.
Dr. Hardeep Singh, MD, MPH, an expert in diagnostic safety for the VA Medical Center in Houston and a Professor of Medicine for Baylor College, says that healthcare is striding through the 2020s with its best tools yet to continue improving. To improve diagnostic safety, he recommends focusing not just on individual performance, but also on the performance of the system where clinicians practice. For example, an organization must first measure its current rate of diagnostic error—which is easier said than done.
Use Accessible Data to Measure Diagnostic Error
For those planning to improve diagnostic safety in their own institutions, Dr. Singh suggests four potential sources of data:
Use the data that are already available. Adverse event reports, medical malpractice data, and patient complaints present learning opportunities. Solicit reports from clinicians about diagnostic errors and near misses. Most reports come from nurses, pharmacists, and other allied health professionals. Many clinicians are reluctant to report. Find a way to invite their information that makes sense for your organization.
Learn from patients. At many institutions, patient complaints are being gathered but not being harvested for signals for improvement. Meanwhile, researchers hear patients say things like, “I kept telling them about this specific concern, but they didn’t listen to me.” Whether it is a case of misaligned expectations or actual diagnostic error, every patient complaint is an opportunity to learn. Open notes could also be leveraged for improvement opportunities.
Make your EHR work for you. Your EHR can help you identify patients with diagnostic concerns by flagging records selectively with e-triggers. For instance, you might view only records that fit a certain clinical profile versus all records. Two examples include: (a) a low-risk patient who is transferred to ICU or initiates a rapid response team within 15 days of admission, or (b) a patient who visits primary care, followed by an unplanned hospital admission within 14 days. These scenarios invite us to ask if there was a missed red flag.
In healthcare, and especially in any fragmented healthcare systems, the responsibility of who is doing what may not always be clear. Here is an example of ambiguous responsibility that Dr. Singh discussed: A primary care physician refers a patient to a pulmonologist. The pulmonologist orders a test that returns an abnormal finding. An EHR will alert both clinicians of that result, so who is responsible for follow-up? What Dr. Singh’s team found is that each might think it’s the other. To address ambiguous responsibility, all organizations should create, formalize, and promote a crystal-clear policy regarding who is responsible for followup of abnormal test results and in what time frame.
Close the Calibration Gap With Feedback
Calibration is the alignment between diagnostic accuracy and a physician’s confidence in that accuracy. For a vignette study,1 physicians were presented with sample cases, both relatively easy and hard to diagnose. Physicians were asked for their differential diagnoses and their confidence in their differential diagnoses. Before they rendered their final diagnosis for each case, physicians were asked if they had resource requests, such as wishing to consult a colleague, desk reference, or web-based tool. Dr. Singh and fellow researchers had hypothesized that when cases were more difficult, clinicians would seek more
assistance, because they would be very uncertain—but that turned out not to be the case. For the easier-to-diagnose cases, physicians were right about 56 percent of the time, and fairly confident. But accuracy for the difficult cases was below 6 percent—with confidence almost unchanged.
That’s the calibration gap—and it can be closed with feedback. Finding ways to close it will be crucial to our long-term efforts to improve diagnosis. At HRA, among other things, we are working with our emergency department (ED) collaborative on missed strokes. From a small review of 43 HRA cardiovascular diagnostic cases, we saw that 20 of those patients returned to an ED after their first presentation. Of those, 10 presented at a different ED, so the clinicians they first saw probably did not know those outcomes.
Physicians, like all other professionals, need accurate and timely feedback to gauge performance. When patients simply go elsewhere, we lose valuable information.
Make a System-Wide Effort
Dr. Singh’s findings align with our claims experience at HRA and The Doctors Company. Roughly 20 percent of claims involve diagnostic error, and what we learn from such claims has implications for patient safety in all areas of ambulatory, inpatient, and ED care. Examining our medical malpractice claims through the lens of the diagnostic process of care framework created by CRICO, the risk management arm of the Harvard medical institutions, we see that care most often diverges from an optimal outcome early on, with an incomplete history or with a cognitive bias like anchoring or premature closure.
To address these ongoing concerns, which affect clinicians and patients across the spectrum of care, we are engaging in a variety of efforts—from a new project looking at primary care, to partnering with national societies to improve diagnosis and prevent errors.
In envisioning healthcare’s next decade, Dr. Singh sees many promising developments in diagnostic safety, but says we still have miles to go. As we implement new tools and best practices to foster learning and improvement, it’s time to make diagnostic safety not just an individual priority, but also an organizational priority. Choose a Resource
We have more tools than ever before to help us improve diagnostic safety. To begin implementing them, start with any of the valuable, open-source resources below.
Agency for Healthcare Research and Quality (AHRQ): Operational Measurement of Diagnostic Safety: State of the Science
Institute for Healthcare Improvement (IHI): Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era
World Health Organization (WHO): Diagnostic Errors: Technical Series on Safer Primary Care
WHO: Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care
