Archive for the ‘Medical’ Category

For Episode 2, go to Cartoon Network

Sunday 10:30 PM on Cartoon Network Adult Swim

TRANSPLANTING A TWISTED PARODY

by Mike Hale  NYT.com

BY Rob Corddry’s own count, he did a hundred interviews when his Web series “Childrens Hospital” appeared in 2008 in which he said that it was “in no way a television idea,” and that a television version “will never happen.”

So, of course, it happened. “Childrens Hospital” begins its new life as a television series Sunday night, part of Cartoon Network’s Adult Swim programming, making Mr. Corddry either a liar or a very bad prognosticator. As he did postproduction work recently at a North Hollywood editing studio, he chose to plead ignorance when asked why his show, among hundreds of online series, should be one of the few to make the jump to the slightly bigger screen.

“We have a very good relationship with the people over at Warner Brothers,” he said, referring to the company that owns thewb.com, where his show first lived, and is a corporate sibling of Adult Swim. “Beyond that I have no idea.”

He’s more definitive about the inspiration for “Childrens Hospital,” which was born out of the enforced idleness caused by the 2007-8 Writers Guild strike. (The strike was the seedbed for other high-profile Web projects like “Dr. Horrible’s Sing-Along Blog,” with Neil Patrick Harris, and the Lisa Kudrow show “Web Therapy,” which will be seen on Showtime later this year.)

“The idea was born of child abuse, essentially,” Mr. Corddry said. At a hospital with his daughter, who had injured her arm, he was taken by the comic possibilities of the terrifying scene: “scared parents, crying mothers, tiny bodies on tiny gurneys.”

A result was an unsparing parody and, in its twisted way, a celebration of mainstream hospital shows, packed into 10 episodes of about five minutes each. The primary target was “Grey’s Anatomy,” with nods to “ER” and “Scrubs” and a subtext of deep affection for “M*A*S*H.”

Doctors committed darkly humorous varieties of malpractice when they weren’t breaking up or making out, sometimes with their young patients. Mr. Corddry wore slasher-movie clown makeup as Dr. Blake Downs, who refused to operate, believing instead in the healing power of laughter.

Getting the online show made wasn’t necessarily a huge challenge. “Studios were green-lighting tons of Web shows and treating it as near-free development,” Mr. Corddry said. But what made “Childrens Hospital” stand out from the start was its cast, an unusually accomplished group in the anonymous and poorly paid world of Web series.

In addition to Mr. Corddry, with his “Daily Show” and film credentials, it included Megan Mullally (“Will and Grace”), Lake Bell (“Boston Legal”), Erinn Hayes (“Parenthood”), Ken Marino (“Reaper,” “Party Down”), Nick Offerman (“Parks and Recreation”), Ed Helms (“The Office”) and Jason Sudeikis (“Saturday Night Live,” “30 Rock”).

“I don’t know what to say,” Mr. Corddry said. “We got everybody we wanted. We went up to our friends and, uh …. ”

Jonathan Stern, an executive producer and writer on the show along with Mr. Corddry, leaped in. “It was faith in Rob and his abilities and what he’d bring to it,” he said. “And knowing that they’d have a good time on it with their friends, and knowing, what’s the worst that will happen? We’ll have two days of doing so-so material.”

After the Web series was posted, both Adult Swim and Comedy Central approached Warner Brothers with the idea of adapting it for television; Adult Swim won what Mr. Corddry called “a very low-stakes bidding war.” He, Mr. Stern and their fellow executive producer David Wain managed to keep most of the cast together for the television show (Ms. Bell, committed to the HBO series “How to Make It in America,” will appear in only four episodes) while adding new regulars like Malin Akerman, Henry Winkler and Kurtwood Smith.

The quality and familiarity of the ensemble is a large part of the answer to the earlier question Mr. Corddry left hanging, regarding why “Childrens Hospital” has been able to follow the path to television blazed by Web series like “quarterlife” and “Sanctuary.”

“Megan Mullally, herself, green-lights a show,” he acknowledged. “I think that’s our main strength.”

Ms. Mullally plays the Chief, an oversexed chief surgeon who flails about on crutches and is an obvious take-off on Dr. Kerry Weaver, the character Laura Innes played for 15 seasons on “E.R.” She said she called Ms. Innes, a fellow Northwestern alumna, before shooting the Web series: “I was like, mmm, just in case. Just in case. But she thought it was great.”

The actors and writers have more room to breathe now that “Childrens Hospital” is a television series, but not much. The episodes for Adult Swim are 15 minutes long (11 ½ minutes after commercials); they will be shown in a half-hour slot at 10:30 p.m. with another 15-minute show, “Delocated.” The original Web episodes have been combined, two at a time, into television episodes that will be shown beginning Sunday. The new episodes will begin on Aug. 22.

The difference between making 5-minute and 11.5-minute shows was substantial. “Essentially the Web series was a series of sketches,” Mr. Corddry said. “The TV series, there has to be some semblance of a story. Unfortunately, because I have no idea how to write that.”

Mr. Winkler and Mr. Smith help carry the expanded story lines, as a wacky administrator and a villain intent on suppressing a cure for cancer. Mr. Stern cautioned against putting too much stock in the plot, however.

“Eleven and a half minutes made us create the veneer of actual story lines and character growth without requiring that we be committed to that,” he said. “We hit all the beats as if the characters were developing and important things were happening and as if there were a beginning, middle and end to the story, but we don’t really have to get too emotionally invested in any of that.”

One change you might expect would be some toning down of the show’s humor, an alternately surreal and raunchy mélange of situations and jokes involving sex, body parts, sex, children, Sept. 11, Puerto Rican midgets and sex. But Mr. Corddry said that editing the original Web episodes for television had just meant bleeping “about a handful of words.”

“It’s sort of the same tone,” he added, speaking of the new episodes. “We get away with a lot on Adult Swim.”

That freedom is part of the attraction for the actors, who find time for “Childrens Hospital” between or during their better-paying gigs. “This show is like any other show we do except the words on the page were much wackier,” said Mr. Marino, who plays the yarmulke-wearing Dr. Glenn Richie and who has also directed an episode.

He was one of several cast members who had gathered at the studio to do audio looping, talk with me and trade jokes. Rob Huebel, who plays the spectacularly clueless Dr. Owen Maestro, had his own reason for sticking with the show: “It’s opened up a lot of doors for me sexually. I can literally have sex with anyone in this room. Anyone. If I wanted to.”

Mr. Corddry’s hopes were more prosaic, if equally unrealistic in the arena of Web series and 15-minute television shows. “I have no ambitions besides keep doing more seasons, as many as they give us,” he said. “And then eventually we’ll just sit back and make money. Right?”

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As promised, this site received and now posts the letter ( ABMS letter to SenCoffee) from Kevin Weiss MD, CEO of ABMS, opposing the Oklahoma Medical Boards final approval for ABPS diplomats to advertise their board certification. On November 18, 2009 a public hearing to recognize the ABPS as another pathway to ‘Board Certification’ for the purpose of physicians advertising their credentials to the public was granted.
 
The problem with Dr. Weiss’s letter was (1)  it was sent AFTER approval was granted by the Oklahoma Medical Board, AND  (2) after receiving the letter it seems that Senator Coffee contacted influential board member(s) per Dr. Kevin Weiss’s influence, and as a result, the Board overturned their properly considered approval of ABPS  and (3) Dr. Weiss’s ABMS’ letter is filled with propaganda and mischaracterizations, which Senator Coffee obviously did not take the time to check out. 
 
This conduct is, at the very least unethical, and possibly actionable, on multiple levels and a response from the Oklahoma Medical Board, Senator Glenn Coffee and ABMS and ABPS to clarify this issue would be much appreciated.
 
 
Board tampering and misconduct are alleged to have occurred during this period by virtue of interference with the medical board’s decision by parties who are not members of the board.
  LINK:

ABMS letter to SenCoffee

ABMS Resorts to State Board Tampering Part 1

u-of-c1

from Chicago Tribune.com (click for full story)

U. of C. emergency room to get more selective

The University of Chicago Medical Center announced a major restructuring in which it would eliminate 450 jobs.The emergency room of the University of Chicago Medical Center may no longer be for every illness or injury. Have a severe injury from a car accident? Head to the ER. Have pneumonia that can be treated with antibiotics? You may be led elsewhere. That’s because the hospital is changing the way it admits emergency room patients as part of its effort to deal with the worsening economy, a move underscored by Monday’s announcement of 450 layoffs, or 5 percent of its workforce. The U. of C.’s decision to introduce what amounts to a new version of patient triage represents an aggressive and unusual move by one of the city’s premier hospitals to cope with spiraling costs and the long waits for emergency treatment.  Some don’t like the plan, but the U. of C. says it has no choice. The academic medical center in the Hyde Park neighborhood said 40 percent of the 80,000 patients who go to its emergency room each year do not need to be there. These visits cost the hospital tens of millions of dollars a year in time spent by staff and specialists whose attention is redirected to cuts, bruises and other less severe conditions that can be treated at community hospitals or through prescriptions.

In addition, the hospital has been dealing with the rising numbers of uninsured, as well as patients covered by Medicaid, which pays low rates and has been months behind on payments to doctors and hospitals in Illinois. So the hospital is escalating steps to direct these consumers elsewhere, which it says will allow it to focus on treating the sickest of patients, as well as conduct research and train doctors. The U. of C. says its costs are 30 percent to 40 percent higher than community hospitals, which are better positioned to treat a variety of patients. “We are trying to get the right patients to the right doctor at the right time for their disease and disorder,” medical center Chief Executive Dr. James Madara said.

The hospital’s effort to manage patient care began as the Urban Health Initiative with a group of executives that included First Lady Michelle Obama, who was involved in early efforts to educate patients on the best use of the emergency room. Under the escalated program, the emergency department will be reorganized to provide more evaluations from doctors and nurses before care is provided. In the past, the U. of C. treated the patients and then educated them about health clinics, setting appointments at doctor’s offices and community centers for follow-up care. The medical center found in a poll that 60 percent of its patients did not know these community health centers were an option, said Dr. Eric Whitaker, who took over Obama’s duties as executive vice president for strategic affiliations and external affairs in January. Some analysts say the shift in strategy could be risky, particularly if a patient who had a condition that needed the medical center’s attention were to be turned away. “This is tricky,” said Jim Unland, president of The Health Capital Group, a consulting firm based in Chicago. “If patients really need to be in an ER and the U. of C. is turning them away, I have a problem with that. “But if patients can be better served at a primary care clinic or urgent care center, it is a good idea as long as they can get there.” Whitaker said the U. of C. has criteria that nurses and doctors use to make their best judgment—evaluations that routinely are done in emergency departments nationwide. There are times, he said, in any emergency situation where a person is treated and advised to go home only to find out they need to return for more care. “At the end of the day, we want to have quality care and be sure the people are treated in the right place,” Whitaker said.

In some cases, patients will be referred to any of about two dozen health centers throughout the South Side or to either of two community hospitals, Mercy Hospital and Medical Center and Holy Cross Hospital, which have agreed to be partners in the initiative. For some patients, The U. of C. will provide transportation or schedule appointments. “We are trying to streamline the process so that patients get seen at our nearby partners in a much shorter time frame,” Whitaker said.

But it can be confusing for patients who feel they should be able to come to the hospital and get the care they need, particularly from a place like U. of C., which is known for state-of-the-art care. Take Mary Darden, who was rushed to the medical center by ambulance around 8 a.m. Monday and diagnosed with pneumonia. By mid-afternoon, U. of C. doctors recommended that she be transferred to Mercy Hospital, her family said. “Why would you keep moving a 92-year-old woman with pneumonia?” said her daughter, Carol Thomas. Joshua Darden questioned the hospital’s judgment in not admitting his grandmother. “That’s what a hospital is for,” he said. The medical center would not comment on the case, but said pneumonia is a common condition that has resulted in many patients being referred elsewhere.

tired-doc
from Medscape

WASHINGTON (Reuters) Nov 18 – Primary care doctors in the United States feel overworked, and nearly half plan to either cut back on how many patients they see or quit medicine entirely, according to a survey released on Tuesday.

More than half — 60% — of 12,000 general practice physicians would not recommend medicine as a career.

“The whole thing has spun out of control. I plan to retire early even though I still love seeing patients. The process has just become too burdensome,” the Physicians’ Foundation, which conducted the survey, quoted one of the doctors as saying.

The survey adds to building evidence that not enough internal medicine or family practice doctors are trained or practicing in the United States, although there are plenty of specialist physicians.

Health care reform is near the top of the list of priorities for both Congress and president-elect Barack Obama, and doctor’s groups are lobbying for action to reduce their workload and hold the line on payments for treating Medicare, Medicaid and other patients with federal or state health insurance.

The Physicians’ Foundation, founded in 2003 as part of a settlement in an anti-racketeering lawsuit among physicians, medical societies, and insurer Aetna, Inc., mailed surveys to 270,000 primary care doctors and 50,000 practicing specialists.

The 12,000 answers are considered representative of doctors as a whole, the group said, with a margin of error of about 1%. It found that 78% of those who answered believe there is a shortage of primary care doctors.

More than 90% said the time they devote to nonclinical paperwork has increased in the last 3 years and 63% said this has caused them to spend less time with each patient.

Eleven percent said they plan to retire soon and 13% said they plan to seek a job that removes them from active patient care. Twenty percent said they will cut back on the number of patients they see and 10% plan to move to part-time work.

Seventy-six percent of physicians said they are working at “full capacity” or “overextended and overworked.”

Many of the health plans proposed by members of Congress, insurers and employers’ groups, as well as Obama’s, suggest that electronic medical records would go a long way to saving time and reducing costs.

Passed Gas Good for Your Blood Pressure

Posted: November 3, 2008 by Doc in Medical
Tags: ,


Flatulence’s stink may be linked to lower blood pressure
Friday, October 24, 2008 | 12:44 PM ET
from CBC News
The gas responsible for the foul odour of flatulence and rotten eggs may play an important role in regulating blood pressure, Canadian researchers say in a study released Friday.

Hydrogen sulphide — a toxic gas that, among other things, is made by bacteria living in the human intestinal tract — relaxes blood vessels and allows for easier blood flow, according to the study in Friday’s edition of the journal Science.

It is hard “not to overestimate the biological importance of hydrogen sulphide or its implications in hypertension,” writes Rui Wang, a physiologist at Lakehead University in Thunder Bay, Ont. Wang co-authored the study with Lingyun Wu, a pharmacologist of the University of Saskatchewan and other researchers from the Johns Hopkins medical school in Baltimore.

The five-year mouse study found that an enzyme called CSE produced the gas in cells lining the walls of blood vessels throughout the body.

That finding confirmed earlier research that suggested a link between the enzyme and the gas.

In the study, researchers bred mice with lower-than-average levels of CSE and found that the engineered animals had significantly depleted levels of hydrogen sulphide compared to a group with normal levels of the enzyme.

The researchers also found that the mice with CSE deficiencies had blood pressure levels that were 20 per cent higher than the normal mice.

However, when the mice bred for lower CSE levels were given methacholine, a drug given to relax blood vessels, their blood pressure levels were not significantly different than those with normal levels of the enzyme. The researchers said this suggests the gas is responsible for the change in blood pressure.

The findings could lead to new treatments for high blood pressure in humans, said the study authors.

“Now that we know hydrogen sulphide’s role in regulating blood pressure, it may be possible to design drug therapies that enhance its formation as an alternative to the current methods of treatment for hypertension,” study co-author Dr. Solomon H. Snyder, a neuroscientist at Johns Hopkins University, said in a Johns Hopkins news release.

JUST THINK OF THE POSSIBILITIES

The character of a doctor


Commencement address by Atul Gawande, M.D.
Yale Medical School
May 24, 2004

It is an honor to have been asked to come before you on this momentous day. Today marks your graduation not just into a new profession but, more than in almost any other profession, into a new identity. You are a doctor. No matter what you do from here on out—whether you see patients, work in a laboratory or leave science and patients altogether—it will now be a central part of who you are, and over time perhaps the most important part of who you are.

It will be how you’re introduced, for example, no matter how much you might try to avoid it. At a baseball game, a hair salon, fifty years from now at, God forbid, an impotency clinic—they will say, “This is Dan Prince. He’s a doctor, you know.” There is no escape, my friends.

The fact that you are a doctor now will define you not just to patients, but to your friends (who will turn to you in their most desperate moments), to your grocery store clerk (who will figure you are rich), to teenagers (who will know you’ve seen a lot of naked people and ask all kinds of rude questions). Most of all it will define you to our larger society as someone of a potentially distinct and valued character. It’s important to think about what that character is on this day. Not all doctors have it, by any means, and no one has it all the time. But all doctors can have it. And what it is, I think, is a particular kind of strength.

I tend to think in stories. So let me tell you one. When I was a fourth-year medical student, I had a patient who still sticks in my mind. I was on an internal medicine rotation, and I was nearly finished with medical school—in fact, it was right around this time of year. The senior resident had assigned me three or four patients to take primary responsibility for. One was a crinkly, Portuguese-speaking woman in her 70s who, as near as I could tell, had been admitted because—I’ll use the technical term here—she didn’t feel too good. Her body ached. She felt run down. She had a cough. She had no fever. Her pulse and blood pressure were fine. But some labs revealed her white count was up. A chest X-ray showed a possible pneumonia—maybe it was, maybe it wasn’t. So her internist admitted her to the hospital and now she was under my care. I took a sputum culture and, following the attending’s instructions, started her on some antibiotics for this possible pneumonia. I went to see her twice each day for rounds. I checked her vital signs, listened to her lungs, looked up her labs. To me, she stayed more or less the same. Her heart rate went up. Her heart rate went down. Sometimes she was warm. Sometimes she was cold. We’d give her antibiotics and wait her out, I figured. She’d be fine.

One seven a.m. morning on rounds, her heart rate was a little up and her skin was a little warm. She had a low-grade fever. Keep an eye on her, the senior resident told me. Of course, I said, though to me she seemed just as she had been. I made a silent plan to see her in the early afternoon before our usual rounds. But the senior resident went back to check on her twice himself that morning.

It is this little act that I have often thought about since then. It was a small thing, a tiny act of conscientiousness. He had taken the measure of me on morning rounds. And what he saw was a fourth-year med student, with a residency spot already lined up in general surgery, on his last rotation. Did he trust me? No, he did not. So he checked on her himself.

That was not a two-second matter, either. She was up on the fourteenth floor of the hospital. Our morning teaching conferences, the cafeteria, everything we had to do that day were on the bottom two floors. The elevators are notoriously slow. He was supposed to run one of the morning teaching conferences. He could have told a junior resident to go up and see her. But he didn’t. He made himself go up.

The first time he went up, he found she had a high-grade fever. The second time, he transferred her to the intensive care unit. To my great embarrassment and her great fortune, by the time I had a clue about what was going on, he already had her under treatment for what had developed into septic shock from a resistant, fulminant pneumonia.

What makes you do the right thing? The distinctiveness of medicine is that you are called upon to ask yourself this question almost everyday. And I can tell you—if I may be blunt—that the answer is not joy. Oh sometimes it really is fun. But the truth of medical life is that doing the right thing is often painful—and yet you find a way to do it anyway.

There can be more than one kind of pain involved. There is, for example, what I call the Back Pain. You have one last lab result to check before you go home. But the computer is down. You call the lab. No one’s picking up. So you walk down to the lab and ask someone for the result in person. But no one at the lab can find the sample. You try to ask a phlebotomist to draw another sample. But the phlebotomists have already gone home. So you have to go find the patient and draw the lab yourself. And now they don’t want to be stuck again. That is the Back Pain.

Then there is the pain of humiliation—because there is always something important that you do not know or are not very good at yet. There is the pain of uncertainty—because nothing is ever sure about people and what goes on inside them and what happens with what we do to them. And finally, there is the pain of failure—because all of us will fail.

Yet a doctor—the doctor others count on and see in you—finds a way to make him- or herself do the right thing. Why? Because you said you would. Because it’s what you chose to do.

* * *

We have certain theories about why people become who they become in life. The most common theory—especially about doctors and artists—is that you are born to what you do. And I know for sure that this isn’t true. Because of all things I could have become a writer was not going to be one of them.

The truth is that before seven years ago, I never really knew how to write and I did not much care. I grew up in a small Ohio town in a family of immigrant doctors. My sister and I were not raised with books around us. The magazines on our living room coffee table were my parents’ medical journals. My high school English classes only required us to read one book cover to cover each quarter. And that was fine with me.

I got a C on my first paper in freshman writing at Stanford. (And if any of you know Stanford, you know how hard it is to get a C there.)

In college I did take a fiction writing class once, but it was mainly because there was a girl taking it I had a rather keen interest in—we married a few years later—and the professor half way through took me aside and suggested I find something to do other than writing.

I can tell lots of stories like these, unfortunately. After college I used to write rock songs with the most abominable lyrics—“Oh the pain, oh the misery,” that gloomy, Morrisey, ’80s sort of thing.

I liked imagining myself as some kind of writer or artist. But I never took the time to actually write—to think carefully and rigorously and unsentimentally about words. What I liked imagining, really, was just being important. But you know where that gets you: nowhere.

Where I eventually ended up after college was medical school. If I was going to be born to do anything, medicine was it. I grew up in a medical family. My father is a urologist, my mother a pediatrician. I don’t like the idea that I became a doctor just because my parents are doctors, and I never did. I like to think of myself as an autonomous being, the master of my own fate. One of my favorite books in the world is Tobias Wolff’s memoir This Boy’s Life. It is the tale of his childhood growing up in Concrete, Washington, with a loving but poor and abandoned mother, a malevolent new stepfather, and a decision he made when he was 12 years old—he simply decided—that he was meant for a better life. During school he stole some letterhead, made up a transcript, several stunning letters of recommendation, and got into a private eastern boys school on scholarship. From there he went to Princeton. And with that he became almost exactly who he had wanted to be—a writer, for one thing, and a person with a certain place in the world.

I took a lesson from this: not that you have the power to simply make up who you are. But you can choose to put yourself in a new and specific world and that will change who you are. Ernest Hemingway was the son of a prominent surgeon and like almost every child of doctors he found it difficult to escape the belief that a doctor is what he had to become. But it was not what he wanted and against his father’s deepest wishes he removed himself to Paris and submerged himself in the expatriate community of artists and writers there and emerged a writer himself.

And yet no one entirely invents themselves. Indeed, a recurring theme of Hemingway’s Nick Adams stories—his first short stories—is the struggle of young Nick to establish his own identity and beliefs separate from his surgeon-father. And by Tobias Wolff’s second book, In Pharaoh’s Army, Wolff has clearly not entirely escaped Concrete, Washington, and his absent, alcoholic father has come out of the woodwork and inserted himself disastrously back into Wolff’s life.

Well, after college I too removed myself to Europe, to Oxford for two years to study politics and philosophy, and put a hold on medical school plans. I hoped to become transformed, to become a thinker, perhaps a professor of philosophy. But it took all my capacity just to understand the questions philosophers asked, let alone offer anything like original answers. I had no natural ability in this and, though I came back a bit better educated and better traveled, I was not fundamentally changed. I spent a further year working in Washington politics. But by 1990 I was a student in medical school and right back where everyone had always predicted I would be.

Later in medical school, however, I chose surgery because I thought that perhaps this would make me more like the kind of person I wanted to be. Certainly I loved technique and using my hands and the sheer blood and guts of it all. But what most attracted me was the predicament of surgery—the combination of high stakes and uncertainty—and the character of those who could deal with it well. Surgeons are faced every day with unknowns. Information is inadequate; the science is ambiguous; one’s knowledge and abilities are never perfect. The risks of unforeseen consequences and terrible mistakes always loom. And yet they are able to act. “Sometimes wrong, never in doubt,” people say about surgeons, and it is meant as a reproof. But this seemed to me their strength—the ability of the best surgeons (like the best politicians) to make wise decisions under conditions of deep uncertainty and accept responsibility for the consequences.

I have always had a tendency to indecision. I could imagine myself in that old New Yorker cartoon with the gravestone inscription that said: “He kept his options open.” So I put myself in the surgical world—where decisiveness is valued not despite the stakes being high but because they are.

This is, in fact, a central trait of good doctors in any part of medicine, I learned. They struggle against the pain of uncertainty, tedium, and error, knowing they will sometimes fail, but doing so because the stakes are high. I also found, much to my surprise, that trying to understand this struggle would lead me to become the writer I did not expect to be.

The life of a doctor is an intense life. We are witnesses and servants to individual human survival. The difficulty is that we are also only humans ourselves. We cannot live simply for patients. In the end, we must live our own lives. Still, to live as a doctor is to live so that your life is bound up in others’ and in science and in the messy uncertain connection between the two.

The legendary baseball coach Lou Pinella once remarked about a young player he thought was not good enough: “He will never amount to much. He never became comfortable with being uncomfortable.”

Graduates, we are the ones who must become comfortable with being uncomfortable—and it is so that others may be comforted.

Thank you.

“Better” by Atul Gawande


Behaviors that undermine a culture of safety
from JCAHO Sentinel Event Alert

Intimidating and disruptive behaviors can foster medical errors,(1,2,3) contribute to poor patient satisfaction and to preventable adverse outcomes,(1,4,5) increase the cost of care,(4,5) and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. (1,6) Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.(2) Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.(7, 8, 11) All intimidating and disruptive behaviors are unprofessional and should not be tolerated.

Intimidating and disruptive behaviors in health care organizations are not rare.(1,2,7,8,9) A survey on intimidation conducted by the Institute for Safe Medication Practices found that 40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator.(2,10) While most formal research centers on intimidating and disruptive behaviors among physicians and nurses, there is evidence that these behaviors occur among other health care professionals, such as pharmacists, therapists, and support staff, as well as among administrators. (1,2) Several surveys have found that most care providers have experienced or witnessed intimidating or disruptive behaviors.(1,2,8,12,13) These behaviors are not limited to one gender and occur during interactions within and across disciplines.(1,2,7) Nor are such behaviors confined to the small number of individuals who habitually exhibit them.(2) It is likely that these individuals are not involved in the large majority of episodes of intimidating or disruptive behaviors. It is important that organizations recognize that it is the behaviors that threaten patient safety, irrespective of who engages in them.

The majority of health care professionals enter their chosen discipline for altruistic reasons and have a strong interest in caring for and helping other human beings. The preponderance of these individuals carry out their duties in a manner consistent with this idealism and maintain high levels of professionalism. The presence of intimidating and disruptive behaviors in an organization, however, erodes professional behavior and creates an unhealthy or even hostile work environment – one that is readily recognized by patients and their families. Health care organizations that ignore these behaviors also expose themselves to litigation from both employees and patients. Studies link patient complaints about unprofessional, disruptive behaviors and malpractice risk.(13,14,15) “Any behavior which impairs the health care team’s ability to function well creates risk,” says Gerald Hickson, M.D., associate dean for Clinical Affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. “If health care organizations encourage patients and families to speak up, their observations and complaints, if recorded and fed back to organizational leadership, can serve as part of a surveillance system to identify behaviors by members of the health care team that create unnecessary risk.”

Root causes and contributing factors

There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.(10) Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it. (9,11) Intimidating and disruptive behavior stems from both individual and systemic factors.(4) The inherent stresses of dealing with high stakes, high emotion situations can contribute to occasional intimidating or disruptive behavior, particularly in the presence of factors such as fatigue. Individual care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior.(8,11) They can lack interpersonal, coping or conflict management skills.

Systemic factors stem from the unique health care cultural environment, which is marked by pressures that include increased productivity demands, cost containment requirements, embedded hierarchies, and fear of or stress from litigation. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the health care team, (5,7,16) as well as by the continual flux of daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for inter-professional communication and for the development of trust among team members.

Disruptive behaviors often go unreported, and therefore unaddressed, for a number of reasons. Fear of retaliation and the stigma associated with “blowing the whistle” on a colleague, as well as a general reluctance to confront an intimidator all contribute to underreporting of intimidating and/or disruptive behavior.(2,9,12,16) Additionally, staff within institutions often perceive that powerful, revenue-generating physicians are “let off the hook” for inappropriate behavior due to the perceived consequences of confronting them.(8,10,12,17) The American College of Physician Executives (ACPE) conducted a physician behavior survey and found that 38.9 percent of the respondents agreed that “physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behavior problems than those who bring in less revenue.”(17)

Existing Joint Commission requirements

Effective January 1, 2009 for all accreditation programs, The Joint Commission has a new Leadership standard (LD.03.01.01)* that addresses disruptive and inappropriate behaviors in two of its elements of performance:

EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.

EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.

In addition, standards in the Medical Staff chapter have been organized to follow six core competencies (see the introduction to MS.4) to be addressed in the credentialing process, including interpersonal skills and professionalism.
Other Joint Commission suggested actions

1. Educate all team members – both physicians and non-physician staff – on appropriate professional behavior defined by the organization’s code of conduct. The code and education should emphasize respect. Include training in basic business etiquette (particularly phone skills) and people skills.(10, 18,19)
2. Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline in a positive fashion through reinforcement as well as punishment.(2,4,9,10,11)
3. Develop and implement policies and procedures/processes appropriate for the organization that address:
* “Zero tolerance” for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Incorporate the zero tolerance policy into medical staff bylaws and employment agreements as well as administrative policies.
* Medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a health care organization should be complementary and supportive of the policies that are present in the organization for non-physician staff.
* Reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive and other unprofessional behavior. Non-retaliation clauses should be included in all policy statements that address disruptive behaviors.
* Responding to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors. The response should include hearing and empathizing with their concerns, thanking them for sharing those concerns, and apologizing.(11)
* How and when to begin disciplinary actions (such as suspension, termination, loss of clinical privileges, reports to professional licensure bodies).
4. Develop an organizational process for addressing intimidating and disruptive behaviors (LD.3.10 EP 5) that solicits and integrates substantial input from an inter-professional team including representation of medical and nursing staff, administrators and other employees.(4,10)
5. Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution.(4,7,10,11,17,20) Cultural assessment tools can also be used to measure whether or not attitudes change over time.
6. Develop and implement a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients.(10,17)
7. Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behavior. Include ombuds services(20) and patient advocates,(2,11) both of which provide important feedback from patients and families who may experience intimidating or disruptive behavior from health professionals. Monitor system effectiveness through regular surveys, focus groups, peer and team member evaluations, or other methods.(10) Have multiple and specific strategies to learn whether intimidating or disruptive behaviors exist or recur, such as through direct inquiries at routine intervals with staff, supervisors, and peers.
8. Support surveillance with tiered, non-confrontational interventional strategies, starting with informal “cup of coffee” conversations directly addressing the problem and moving toward detailed action plans and progressive discipline, if patterns persist. (4,5,10,11) These interventions should initially be non-adversarial in nature, with the focus on building trust, placing accountability on and rehabilitating the offending individual, and protecting patient safety.(4,5) Make use of mediators and conflict coaches when professional dispute resolution skills are needed.(4,7,14)
9. Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, (11) with adequate resources to support individuals whose behavior is caused or influenced by physical or mental health pathologies.
10. Encourage inter-professional dialogues across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.(1,2,4,10)
11. Document all attempts to address intimidating and disruptive behaviors.

LINKS:
JCAHO Sentinel Event Alert
Better Hospital Manners by Mandate from WSJ