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Saturday, September 22, 2018

Mass. ICU Nurse Staffing Regulations Did Not Improve Patient Mortality and Complications | BIDMC

Similarly, lack of better clinical outcomes were found when increasing critical care physician staffing in ICUs. Having doctors (intensivists) around the clock in the ICU did not confer better outcomes but did increase the number of things done (lab orders, studies, procedures, etc) and did increase the patients' bill. Doing more did not mean saving more [lives, complications, cost, or days in the hospital]. A paradox in healthcare policy making is that we seem to make regulations and laws before we have determined benefit (or lack thereof). Medicine is meant to be evidence-based meaning we test a hypothesis for benefit, harm or no effect before ever applying a practice to patients. This is how medical science is done. Yet, in the realm of healthcare policy making this is not so. We make policy without testing whether the assumption is true or false. In this case, the hypothesis may be that, "Decreasing ICU patient-to-nurse staffing ratios affects mortality rates, medical complications and length of stay." Legislators could then request such a study, collect and analyze the data then make or not make legislation based on the evidence. In this case, the premature making of a law by Massachusetts lawmakers is not supported by post hoc evidence--putting the cart before the horse as the saying goes. And we all know, once on the books, how difficult it is to recall a law, regulation, policy, or rule. This type of premature legislating without evidence basis is the norm in healthcare policy making (ACA, HITECH Act, Meaningful use, and many, many others from federal level to state to the local policies of hospitals in your town). Healthcare policy makers should be required to take a course in the scientific method: 1) Step 1: Ask a question. 2) Step 2: Form a hypothesis. 3) Step 3: Test the hypothesis. 4) Step 4: Observe and Record. 5) Step 5: Draw conclusions. 6) Step 6: Share findings with stakeholders. 7) Step 7: Formulate policy. Let's make health care policy with the same rigor with which we practice health care.
from Rajesh Harrykissoon, MD

Wednesday, September 19, 2018

Doctors are known for their poor bedside manner. Robots might be the answer

I don't believe AI robots are anywhere close to understanding semantics much less the difference between syntax and semantics. Communication may be broken down into two things: syntax and semantics. The term syntax refers to grammatical structure whereas the term semantics refers to the meaning of the vocabulary symbols arranged with that structure. A robot may correctly interpret, "Let's eat, Grandma!" and incorrectly interpret "Let's eat Grandma!" But, a human appreciates the semantics and doesn't make Grandma the main course at dinner. Human communications also flexes for the recipient's communication style. That is, how I encode a message depends on how the recipient decodes the message. Personality traits may correlate with this type of communication flexing. For instance, I once walked into an ICU room my first day returning to service only to be greeted immediately with the patient's pointed question, "Am I going to die?" To which I said, "Yes." The patient responded, "Thank you. I've been trying to get that answer but everyone keeps pussyfooting around it and are marshmallows for not wanting to hurt my feelings." By outside perspective that initial interaction may seem "poor bedside manner." Who answers in such a way with zero patient relationship? I knew a few things which informed my response. One, she had a terminal condition which ultimately leads to death about five years after initial diagnosis (on average). Two, the patient had a one week ICU length of stay and counting. Three, she addressed me in a matter of fact manner (encoding). Four, although bed bound, her movements were quick, active, purposeful. She exercised command and control of the environment including of the health care team (nurses, ancillary staff, etc). And, five her eyes were bright, inquisitive, directed. I assessed all of this within moments of arriving outside her room to entering with the reception of, "Am I going to die?" No good morning, no introductions, no chit chat, no background clinical recap.... Our continued conversation progressed on a very productive tract. The patient made plans, mobilized family from out of state and died with closure and piece 3 days later. In other patient interactions I am that "marshmallow" taking a slower, gentler communication style because that's what their communication encoding required. How might a robot interpret my initial bedside manner?
from Rajesh Harrykissoon, MD

Saturday, September 15, 2018

Texas A&M welcomes national center to improve rural health care - Vital Record

In operationalizing this grant, I would hope the A&M Rural and Community Health Institute keeps in mind the lessons we have learned since the 1990s regarding health services utilization--that of psychological distance. The natural assumption is that more brick and mortar locations directly correlates to better health care; that is, proximate geographic access effects better health care. However, this assumption was proven false in the mid-1990s by the near financial devastation of the Kaiser system which practically placed a clinic in everyone's backyards, yet utilization did not increase. Subsequently, in the decades since Kaiser's experience this assumption has been proven false over and over. The true barrier appears to be not that of geographical access but that of "psychological distance." Psychological distance is the new sexy term that has replaced psychological aversion in the health care utilization literature. What it means is that people have a natural bias to avoid health care contact. Health care contact is seen as a tax on time which may be more joyfully spent. Would you rather spend an afternoon in a clinic's waiting room or have that time as relaxation time, family time or time with a book on the back patio? The argument of downstream benefit--the preventative clinic visit means better health and quality of life rewards down the road--appears to be insufficient to narrow this psychological distance. Thus, a clinic in one's backyard might as well be on Mars. Until the psychological distance is narrowed, effective health care utilization may be poor.
from Rajesh Harrykissoon, MD

Saturday, September 8, 2018

Should I Screen

Quiz. Should you get screened for lung cancer? Take the quiz. Schedule an appointment (979-694-1300) if screening is indicated.
from Rajesh Harrykissoon, MD

Friday, August 31, 2018

His $109K Heart Attack Bill Is Now Down To $332 After NPR Told His Story

I don’t believe narrow network options should exist for true emergencies. The problem is that for every one true emergency, there are a dozen or more non-emergency visits. The health insurer is stuck paying a premium for those convenience visits. Many insurers have tried to curb convenience utilization of EDs through creation of narrow networks and even post-ED visit denial of claim (if the visit was deemed not a true emergency). What’s the optimal solution?
from Rajesh Harrykissoon, MD

Saturday, August 25, 2018

Reading the new blood pressure guidelines - Harvard Health

Blood pressure maintenance in the normal range (less than 120 mmHg) has to start early--in the teens and age 20's--while it is still in the normal range. I suspect if your blood pressure has been elevated--let's say systolic 140's mmHg--for decades and now you're trying to get it to less than 120's, it may be too late to do so immediately without consequence. That's because the vascular remodeling which have occurred over the decades at blood pressure of 140's result in a diastology which is no longer favorable for hemodynamics at less than 120's. In essence, the arteries become harder, stiffer, with less elasticity for both distention and recoil. Imagine an old dry-rotted radiator hose (for those old enough to recall those days). :) I think more responsibly the management ought to target a percent reduction from baseline blood pressure. And, proven well tolerated, a continued and progressive approach to control.
from Rajesh Harrykissoon, MD

Thursday, August 23, 2018

Preserved anabolic threshold and capacity as estimated by a novel stable tracer approach suggests no anabolic resistance or increased requirements in weight stable COPD patients

Our latest publication in collaboration with the Texas A&M Human Research Center. We are gaining tremendous insight into the metabolic function in those with chronic diseases such as COPD, sleep apnea and heart failure. We are still recruiting patients for ongoing work. Thank your to all my patients who have made this research and contribution to science possible. If you are interested in participating in such valuable research with an awesome team in the beautiful new research center, please contact our office for an evaluation.
from Rajesh Harrykissoon, MD