Nursing Staffing Levels Threaten Patient Care

On the day that I penned this post, I rounded at our community hospital.   My first patient was in the step-down unit, which houses patients who are too ill for the regular hospital floor.   I spoke to the nurse in order to be briefed on my patient’s status.  I learned that this nurse was assigned 6 patients to care for – an absurd patient volume for a step-down unit.  “Why so many patients?” I asked.  She explained that some nurses called off work and the patients had to be spread around among the existing nurses.

This occurs every day in every hospital in the country.  Nurses are routinely required to care for more patients than they should because there is a nursing shortage on a particular day.  Why do hospital administrators allow this to happen?  If any are reading this post, I invite your response.  Enlighten us.  When a nurse is overburdened, how do you think this affects quality of care and nursing morale?

I suppose it saves a few bucks on payroll, but this strikes me as very short term gain that risks medical and financial consequences.   Providing high quality medical care can’t be a rushed effort.  If a nurse’s job description increases by 30%, do you think the quality of care and patient/family satisfaction won’t decline?   Don’t administrators fear the risk of medical errors from overworked nurses?  Would any of them like to be patients under these circumstances?

Nurses Need Help

Nurses have confided to me for years how demoralized they are that no one speaks for them.  Instead of watching their backs, they often feel that they are stabbed in the back.

I do not have warm feelings for labor unions and I support right to work initiatives.  But, when I see what nurses endure and the lack of support that they receive, I would support them if they moved to organize.

If a 3^rd grade teacher is ill, we expect a substitute teacher to be called in.  The third graders are not simply herded into another classroom expecting one teacher to handle a double load. 

Many of us today are asked to do more with less.  Teachers, law enforcement, businessmen and government program administrators know this well.  At some point, you aren’t cutting fat anymore, but are slicing into bone. We are not taking proper care of those who have dedicated their lives to care for us.  Who will heal the healers?

Why I'm Against Medical Marijuana

I have already opined on my disapproval of a medical marijuana law recently passed in Ohio.  Once of my points in that piece is that I did not want legislators making medical decisions for us.  They can’t even do their own jobs.

I am not against medical marijuana; I am for science.  The currency of determining the safety and efficacy of a medicine should be medical evidence, not faith, hope or belief.

Marijuana is a Drug Enforcement Agency (DEA) Schedule 1 drug, alongside heroin, LSD and Ecstasy.  I realize this seems odd since most of us do not believe that marijuana has the health or addictive risks of the other agents on the list.  It doesn’t.  But, danger is not the only criteria used in determining which category a drug belongs in, a point often misunderstood or ignored by medical marijuana enthusiasts.  An important criterion of Schedule 1 drugs is that they are deemed to have no proven medical use.

The federal government recently affirmed marijuana’s Schedule 1 status, which disappointed those who argue that this agent is the panacea, or at least an effective treatment, for dozens of ailments.  The government disagreed.  It reviewed several hundred medical studies and only identified 11 of them that were of sufficient scientific quality worthy of consideration.  None of them demonstrated a salutary effect of marijuana.

DEA Holds Firm 

An advocate of medical marijuana use was railing against this decision and stated that 80% of Americans believed marijuana had medical value.  His point demonstrates the vacuousness of his argument.  He might support letting polling determine if a drug is safe and effective; but I trust the FDA and hard science to make these determinations.

I am sure that if we polled the public on the medical benefits of probiotics, gluten restriction, GMO foods,  organic foods, radiated foods, colonic detoxification, yoga, veganism and meditation that we might find that the public’s belief in these practices doesn’t have firm scientific support.   I do not argue that these dietary and lifestyle practices do not have health benefits or enhance life in other ways, only that they are either unproven or disproven.  There are still folks out there who believe that the measles vaccine causes autism, even though this theory has been thoroughly debunked. In my view, releasing a medicine to market requires firm scientific support.  Anecdotes and low quality ‘studies’ should be afforded the weight they deserve.

Should we open up the gates to all kinds of potions and elixirs that are unproven for the public?  We do!  They are called dietary supplements.  These agents are considered safe until they are proven to be dangerous.  Is this the standard we want for prescription drugs?

Nursing Documentation vs Patient Care - Who's Leading?

I work with nurses every day.  Anyone who doesn’t realize how hard these professionals work, has never been in a hospital.  Their job descriptions have expanded along with their work load.  This is not your father’s hospital ward.  Hospitalized patients today are older and sicker than ever before.  It takes a seasoned nursing professional to manage the care of these complex patients.   Their work days are full simply managing the expected tasks of dispensing medications, coordinating diagnostic tests and assessing their patients.  There is no time scheduled for unexpected events, which are expected as sick people’s conditions may change at any moment.  In other words, if a nurse must attend immediately to a patient with chest pain, then his or her other more mundane tasks are delayed or shifted over to another busy nurse.

I believe that the most potent barrier that is separating nurses from their patients today is the ferocious documentation mandates that nurses are required to perform.  The hospital corridors are clogged with nurses hovering over computers entering all kinds of data, most of which will never be viewed by physicians.   These nurses are not techies who want to be palpating a keyboard.  They are compassionate caregivers who want to be in their patients’ rooms caring for them.

Tomorrow's Nurse?

If you suspect that I am exaggerating here, then go ask a nurse.

Moreover, the hospital’s electronic medical record system has become deeply layered and complex. Often I can’t find the specific data I need.  Just last week, a couple of senior nurses and I were scouring through the computer to find a patient’s result of stool testing for blood.  We simply couldn’t find it, and these nurses are pros.  At that point we were left with the following options:

• Reorder the test
• Make up the result
• Quit the profession and become an Uber driver
• Ask the patient what the result was
• Hire a 12-year-old who could find the results in a few seconds.

While the computer record is packed with data concerning every aspect of the patient's medical experience, I have my own approach to find out what’s going on.  Pay close attention here.  Read the next sentence very slowly as I want readers to grasp the complex process I use each day as I approach the nurse.

“Hi.  What’s going on with my patient?”

Labor Day 2016

Honoring work.

Mylan Defends EpiPen Price Hike

Why do smart people often do dumb things?  Would you plagiarize a speech that you know is going to be carefully scrutinized?   Would you respond to a robocall that congratulates you on winning a free cruise?  Would you keep eating sushi that didn’t smell right? 

I’m certainly not judging anyone here.  I’ve had plenty of my own misadventures and I periodically add to the list. 

Our presidential candidates fall prey to human error and misjudgments surprisingly often.  Aren’t these folks supposed to be pros or at least managed by honed handlers?  Why would Donald Trump have insulted nearly every constituency and rival during the primary election process knowing that this might render him unelectable in the general election?  Why would Hillary Clinton demand unconscionable speaking fees from special interest groups when she knew that she would pursue the presidency and her payoffs would be publicized?

I’ll leave it to readers to ponder their own responses to the above inquiries.

If the sushi doesn't pass the sniff test, head to Burger King.

Last year, I posted on a drug company that raised the price of a pill from $13.50 to $750.00.  Even if such a practice is legal, or is justified by market forces, it is very, very dumb.  It is guaranteed to provoke outrage and will surely result in scrutiny that will go much wider and deeper than the initial offense.  It did.  For more details, just click here.

One would think that rival pharmaceutical companies would be more cautious before enacting similar price gouging.   Guess again.  Mylan, who makes EpiPen, raised the price of this product about 500% over the past years, bringing the price to $608 for a two pack.   The company stands by the new pricing.  Sure, they have offered a few discount coupons, but they are leading from way behind. They are not likely to prevail, even if they have a potent economic argument.  

This stuff is ripe grist for politicians, who can rail against the pharmaceutical barons, in order to distract the public from their own abysmal performance.  And, angry parents will use social media and other methods to publicize their outrage.  The fact that many patients who rely upon EpiPens are young children doesn’t make the company’s case any easier.  

If Mylan’s CEO Heather Bresch is called to testify, how will the optics be when she states that her compensation last year was about $19 million?

Why are so many pharmaceutical folks so allergic to good judgment?  Perhaps, they should carry around an EpiPen, if they can afford it.

Who is Responsible for Prescription Drug Abuse?

I have written about pain medicine previously on this blog, and it generated some spirited responses.  Let me be clear that I am completely against all forms of pain, whether foreign or domestic, physical, spiritual, psychic or even phantom.  The medical profession has superb tools to combat and relieve pain, and physicians should utilize them, within the boundaries of appropriate use.  We now have an actual specialty – pain management – who are physicians with special training on the science and treatment of all varieties of pain.  I utilize these specialists when necessary and I am grateful for the help they provide to my patients. 

There are two forms of drug abuse in our society – legal and illegal.  The latter has become a health scourge that is shattering families across the country.  A few days before I wrote this, I read the stats of overdose deaths in my state of Ohio.  I was shocked to learn that in our state alone, we lose thousands of individuals every year to drug overdoses, most of which are not intentional.  The street drugs are often impure, or laced with potent additives or substitutes that become a fatal concoction.   Extrapolating Ohio’s stats across the country would create a stunning number of drug deaths.  The causes and the potential solutions to this plague are vexing, but must be pursued.

An Opium Poppy - Cure or Disease?

There is also a legal avenue for drug abuse, medicines prescribed by doctors.  This sphere of abuse will be easier to control than the illegal counterpart, as the process is initiated by a doctor’s prescription and subsequently involves a pharmacist.  No doctor or pharmacist wants to be a pawn in this game.  I believe that these professionals have adapted to a looser culture of prescribing pain medicines and changing expectations on pain relief of the public.

Consider this staggering statistic:  According to the National Institute on Drug Abuse, Americans consume more than 80% of the planet’s opioid medicines, yet are less than 5% of the world’s population.  Does this make any sense?   Would advocates of the status quo argue that America has nearly 20 times more pain than other nations have?

I can state plainly that I have never seen so many patients in the hospital who are on intravenous and powerful narcotics for stomach pain.  These same patients a few decades ago were treated differently, and I recall that we kept most of them reasonably comfortable.  The risks of narcoticomania are self-evident.   Many patients and their families are suffering heartache and misery whose origin can be traced back to a narcotic prescription.  This is a great tragedy.

Narcotics have an important role in our patients’ care, and I support their appropriate use.  There are patients who need opiod use to manage chronic conditions.  But, opiods and narcotics are overused and we need to admit this so we can begin to remedy this reality.  Physicians and the public need to reach an understanding on what each expects from the other.  Both doctors and our patients need more training on this issue.  Doctors should do all we can to make our patients comfortable.  Indeed, relieving pain and suffering is fundamental to the healing mission.  Patients should recognize that physicians may not be able to guarantee 100% pain relief for every situation that you may face.   We have an obligation to minimize your pain and discomfort, but also a responsibility to protect you from wandering down a dark and destructive path that may lead you ensnared in a den of demons.

Are Doctors Paid Too Much?

Years ago on Cape Cod, my kids and I stumbled across a man who had spent the day creating a sand sculpture of a mermaid.  It was an impressive piece of art.  “How long did it take you to make it? ” we asked.   While I can’t recall his precise words, the response was something like “25 years and 7 hours”.  I’m sure my astute readers will get his point.

We are transfixed now watching Olympic athletes performing in Rio.  So much depends upon their brief routines which can last seconds to a few minutes.  While a diver’s acrobatic plunge may take 2 seconds, it would not be fair to leave aside the years of work and training that prepared the athlete for this moment.

The same point can be made for anyone who has worked and trained hard to reach a point where the action performed seems easy to a spectator or a customer.   If an attorney prepares estate documents, we can assume that the fee for this reflects the prior training and research that the lawyer has done on this issue, as it should.  If an appliance repairman, by virtue of his expertise, fixed our ailing washing machine in 5 minutes and charged us $100, should we balk at this price gouging?  If a less skilled competitor spent 2 hours before finding and correcting the glitch, would we feel better about handing over $100?  Is this fair?  A musician doesn’t just wake up one morning and hop onto a stage to give a concert.  When we pay to listen to an artist perform for 2 hours, we are likely listening to the product of years of grinding work, disappointment, innovation and discovery.

What's a fair price for an hour of Aretha?

I believe that this same principle applies to my own profession.  Over the years I have heard patients complain about various medical charges and fees. While we all know that there have been excesses, many of their gripes are misplaced, in my view.   It’s not fair to equate the medical fee with the time that the physician expended on providing your care.  A cardiac bypass operation takes just a few hours.  A colonoscopy takes 10 minutes.   Treating a patient in an emergency room with a drug overdose may take just a few hours.  A psychiatrist might guide a suicidal patient to choose another path in half an hour.  A spine injection to relieve chronic pain takes only a few minutes.  A dermatologist recognizes a suspicious lesion in a few seconds.  A seasoned surgeon tells an anxious patient after a 20 minute consultation that surgery is not necessary.

Often, folks who make is all look easy are fooling us.  If we think it’s as easy as it looks, then we’re the fools.