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LGBT Health: Recognizing Disparities and Increasing Support

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by Vadim Shteyler

Amid this week’s disheartening studies highlighting discrimination of LGBT populations, the American College of Physicians (ACP) affirms its support and offers new recommendations for furthering LGBT health.

The bad “news”: is not really news. It is further evidence of how much more effort needs to be placed on ending LGBT discrimination and inequalities. A national survey published in the Ann of Intern Med found that lesbians were significantly less likely to get vaccinated for HPV than their heterosexual counterparts (adjusted prevalence of 8.5% v 28.4%). HPV is easily transmissible through contact and believed to be equally transmissible in gay and heterosexual women. The vaccine can prevent most cases of cervical cancer, which has terrible outcomes if discovered late, indicating that many deaths could have been prevented. An editorial in the same issue describes neglected health concerns affecting LGBT populations and calls for better professional education on LGBT health. The CDC’s and American Congress of Obstetrics and Gynecology’s (ACOG) efforts to inform patients about pap smear rates not been slow and inconsistent in changing medical practice. Combined with markedly lower HPV vaccination rates, cervical cancer remains a big concern. Read More

Quality Measures and Doctor Behaviors

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by Vadim Shteyler

Efforts to improve health care quality under the ACA have been directed towards expanding EHR use and health IT, improving care delivery by promoting care coordination and population health, and laying incentives for providers to meet quality measures. The 33 ACO quality measures include 8 measures to evaluate preventive care, 12 measures to address goals of managing 4 common diseases, and 7 to assess patient satisfaction. Though quality improvements have not been consistently shown, studies have found modest Medicare spending reductions. In fiscal year 2013, CMS began reducing health care reimbursement rates to hospitals with excessive 30-day readmission rates, as generalized by their readmission rates for heart attacks, heart failure, and pneumonias. These were extended to include readmission rates for hip and knee surgeries in fiscal year 2015. And, as readmissions were estimated to account for $17.5 billion of Medicare costs in 2012 (in part attributable to insufficient discharge services, access to outpatient care, and follow-up), efforts to curb them are expected to continue.

The ACO quality measures have been criticized for being too process oriented (as opposed to outcomes oriented). And, undoubtedly, so few quality measures can’t encapsulate all of health care. Noted shortcomings of readmission rates as a valid indicator of quality include that they do not differentiate between planned and unplanned readmissions and they don’t adequately control for different case-mixes between hospitals. As psychiatric illness is often poorly recorded in medical records, it is a major confounder that may impact different hospitals differently. In this blog post, I add the speculative concerns of a medical student from limited experiences on the wards. Read More

Uncertainties in Cancer Screening

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by Vadim Shteyler

A.F. was an elderly patient admitted to our service for a diagnostic work-up and management of a large pocket of pus surrounding her lungs. Until recently, she was very independent and in good health; this was her third hospitalization for the same reason in one month. Radiographic imaging was consistent with pneumonia but other causes could not be ruled out. She had not responded to antibiotics, she had no other signs of infection, and numerous cultures from her blood, pus, and sputum failed to grow microbes. Extensive testing for other possible causes was also negative. At that point, we all had the same suspicion—cancer. Some tumors in the chest can cause inflammation that may look like a pneumonia and result in a collection of pus. That inflammation can also hide the tumor on imaging. In fact, it would be a few weeks, after we drained all of the pus and the inflammation subsided, until we would have a clearer image of the lungs. Though cancer was a plausible explanation, we had no evidence at that time. Should we have discussed our concerns with A.F.? The diagnosis was not certain, so we didn’t…

In daily clinical practice, uncertainties come in many forms. Outcomes for most medical interventions are probabilistic (they are not 100% predictable). And those probabilities are often ambiguous (they are more often ranges than specific percentages) or simply unknown. At a broader level, science is underdetermined, medicine is inductive, and innumerable non-medical forces influence the medical landscape (biases, conflicts of interest, values, etc.).

How effectively providers communicate uncertainty is…well, uncertain. Read More

Unexpected Channels of Patient Misinformation

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by Vadim Shteyler

As a medical student on the wards, physicians often recounted stories of horrifying acts of paternalism from the days of their training. Though paternalism is far from abolished, the progress we have made as a profession has become a source of some pride. On the wards, autonomy has become exalted as a sacred right and invoking paternalism can end most debates. Though autonomy is a complicated and frequently debated concept, most agree that the cultural shift is a step in the right direction. And though perhaps we should be proud of our steps towards protecting the way patients receive information in clinic, we should be more aware of other sources of patient information as well.

Of course, it may not come as a surprise that a lot of the medical information available to patients is less than accurate. With the Internet, ubiquitous misinformation about anything should be expected. However, when we think about the sources of that misinformation we often think about random websites found during quick Google searches, Wikipedia, sensationalized media coverage, and pharmaceutical advertisements (the later will be discussed further below). A few recent studies are bringing attention to more surprising culprits: Hospitals and Academic Institutions. Read More

Should patients be able to limit doctor access to medical records?

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by Vadim Shteyler 

The growing accessibility of Electronic Health Records (EHRs) across hospitals and practitioners raises new concerns about patient privacy. Before EHRs, patients had control over how much information they shared with each healthcare provider. Receiving patient information from other practitioners has required a signed consent form specifying the information patients are comfortable sharing (e.g., radiological studies, mental health history, sexual history, etc.). And hospitalists have been expected to request the minimal necessary information to provide good care. With growing networks and increasing compatibility across EHRs, more providers now have access to information without the patients’ express permission or even awareness.

Recent works published in the Journal of General Internal Medicine reported the results of a study that designed and recorded patient and provider experiences with a patient-controlled EHR (in which patients chose which providers could access which data in their medical records). A preliminary survey showed that, before the study, only 10 percent of patients had access to their medical records. Half of surveyed patients did not know what information their EHR contained. However, all patients wanted access to their EHRs. Meanwhile, another study reported that only one-third of physicians thought patients should have EHR access. Read More

Debate over Resident Duty Hours

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by Vadim Shteyler

On the wards, resident duty hour restrictions were a frequently recurring topic of heated discussion. Effective July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new limitations on resident work hours for all ACGME-accredited residency training programs, furthering the existing limitations from 2003 reform. Current policies restrict workweeks to 80 hours. Residents must get at least four days off every four weeks. Shifts are reduced from 30 consecutive hours to 16 consecutive hours for first-year residents and to 24 hours for all other residents. First-year interns must have eight hours off between shifts. And residents after 24-hour call must have at least 14 hours off.

Proponents argue that exhaustion contributes to medical errors, such as the death of Libby Zion (whose tragedy prompted the conversations and the policies limiting duty hours). Longer hours can lead to poorer quality of life, ultimately harming patient care. And inefficiencies in the more frequent handoffs are reasons to focus attention on handoffs rather than lengthen shifts.

Opponents have an unlikely ally, many residents and physicians. During my rotations, many argued that fewer hours on the wards translates to less real-life patient exposure and under-preparedness for independent practice. Read More

Hospitable Hospitals and the True Cost of VIP Rooms

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By Vadim Shteyler

Increasing hospitality in medical facilities is not a recent trend. We take for granted that modern hospitals offer clean sheets, towels, a plethora of toiletries, heated blankets, and many other amenities. Conversely, in the hospitals of decades past, many patients relied on family members to bring food and clean sheets. Rows of hospital beds in an open ward precluded privacy. Unhygienic conditions commonly resulted in rodent infestations. And paternalism in medicine was still the norm.

This trend towards hospitality has recently gained new momentum. As featured in a recent article in Kaiser Health News, dozens of hospitals have hired Chief Patient Experience Officers from customer service or hotel industries. Since 2012, when Medicare began penalizing hospitals for poor patient experiences, hospital efforts to improve patient satisfaction have grown. Some hospitals began mandating communication seminars, encouraging nurses to spend more face-to-face time with patients, and calling patients after discharge to follow-up on their recovery. The Affordable Care Act (ACA), further tying hospital reimbursements to patient surveys, has additionally promoted such changes.

A similar trend has arisen with the increased popularity of V.I.P. sections in many hospitals. Though the hospital construction boom is beginning to slow down, the resultant V.I.P. rooms remain. Lenox-Hill Hospital’s maternity suite in New York City, which received a lot of media attention after Beyonce gave birth there in 2012, is one of many luxurious suites across the nation. Some, offering personal shoppers, private chefs, and salon services, are priced upwards of $4,000. While nobody calls for a return to the hospitals of old, many feel suites such as these are excessive.  Read More