Better to Best: Thoughts on Global Health Care Systems

If only this was the perfect solution…

Posted in Medical School (General), Patient Quality and Safety by reshmagar on August 9, 2011

A while ago, many of my friends in med school posted this article from the The New York Times Health Blog – lauding the innovative method the doctor used to counsel her patient about their medications. To summarize the article, the author, a physician had a visit with one of her usual elderly patients who was chronically ill with diabetes, hypertension, and high cholesterol. Like many who are chronically ill, the patient had over time been prescribed a slew of medications which he brought to the visit and was confused as to when to take each of them. Turns out he was unable to read the pill bottles as well as the directions the doctor had written out for him the visit before. To solve this dilemma, the author worked painstakingly on a new set of directions;

Mr. M and I opened up his pill bottles. We extracted a pill from each and taped it onto a piece of paper. I drew a sun next to the ones that needed to be taken in the morning, and a moon next to the ones for nighttime. He left my office with sheet of brightly colored pills, a rainbowlike guide that I hoped would offer him access to the quality medical care he surely deserved.

I first came across this article posted on Facebook by some of my friends stating that this would be a great way to tackle non-compliance amongst patients. From my last rotations in psychiatry and Ob/Gyn, I frequently see patients struggle to take their medications at appropriate times for a variety of reasons – sometimes they just don’t like the way the medicines make them feel or feel like they don’t need them or other times, they are unable to access them due to loss of insurance or funds. I read the article hoping to find new insight into this topic only to find an interesting anecdote on patient health literacy and a good method for the patient described in the article.

Regardless, I do agree with the author’s approach to her patient in that she actually spent time to explain the medication regimen. During my first year of medical school, I worked with an Urgent Care Center physician who taught me from day one the importance of not only writing out instructions for the patient and explaining the treatment plan to them but also the need to spend time asking the patient what they understood the regimen to be. In the hospital setting and in other clinics, time is precious and often, patients leave with a stack of discharge instructions with paragraphs regarding their condition and medications as well as prescriptions they have to pick up on their own time. We often at our hospital triage see repeat patients who failed to follow-up with us as directed or pick up their medications causing their medical condition to exacerbate. They return often more sick than necessary and a new treatment plan has to be created. Some are even admitted.

In looking at the problem of health literacy, there are certain pragmatic factors to take into consideration to ensure that patients upon leaving the hospital understand their treatment. For many doctors, time is a limiting factor. In most medical practices including primary care practices, follow-up appointments last approximately 15 minutes. In this time, not only does the doctor have to address any immediate concerns that the patient has, but they also have to ask questions to ensure that they are no other health issues going on the patient may be unaware of as well as a modified physical exam. Usually, the physician also spends a minute or less going over any results and their recommendations.

Additionally, physicians often schedule patients back-to-back which means that any additional time taken with one patient going over medications takes away time from subsequent patients. With the impending shortage of primary care doctors, it is not possible right now to take on less patients. The Affordable Care Act will provide much-needed health care to millions of new patients who will all require a primary care doctor. In line with this, however, there are provisions to build more community health centers but no clear provisions to increase the number of primary care doctors. Until there are more students going into primary care and more incentives to do so such as a salaried position or less overhead costs in a private practice, doctors will probably not be able to spend an extra 15-20 minutes with patients who have complex chronic diseases along with other social issues such as being illiterate. At least, not on a regular day.

During gynecology, one of my attendings set aside one day per week for a chronic pelvic pain clinic where she tailored care for each patient that included long sessions with each person along with regular emails and phone calls. Perhaps, this is the solution in primary care we need. A day set aside for the most complex patients to spend longer amounts of time to construct a comprehensive plan. Rather than being sent to a chronic care specialist, patients who see their primary care doctor more often will get regular check-ins to ensure they understand the plan completely.

Another solution proposed has been to hire a nurse or other practitioner who after each visit will sit down with the patient to go over their treatment plan and check-in with them. This, I also do not see as realistic. With rising overhead costs from the lightbulbs and toilet paper in the practice to paying the billing specialists and receptionists and more and more primary care doctors closing their practice due to these costs, it seems unlikely that hiring someone else to sit down with patients after their visit is a sustainable solution.

Today, I start family medicine. I have no idea where I am going to be placed but I do wonder if I will encounter a similar situation to the one detailed in the New York Times health blog. I would like to think that I will spent the extra time needed but what if my attending expects me to finish the visit within a certain period of time (which has happened) before moving onto the next patient? Then what solution will work then? Will I allow the patient to walk away with a confused look on their face and a statement along the lines of “Well, if you have any questions, feel free to call or email. Okay?” That makes me uncomfortable especially after recently realizing that I am more at peace immediately constructing a flowchart plan and wanting to actively try the best algorithm as soon as possible. I am not comfortable with expectant management usually…but I guess, we’ll see what happens with this rotation.

Does anyone know of solutions to this that have worked that they’ve seen implemented? Any input on this would be much appreciated.

Announcing the Northeast Regional Patient Safety and Quality Improvement Conference

Posted in Patient Quality and Safety by reshmagar on January 27, 2011

For the past year, I have been working on putting together a conference on patient safety and quality improvement. It’s finally coming together and soon approaching in less than 2 weeks! Crazy.

So why should you come?

When I was an undergrad, I had the opportunity to attend a dinner with a patient presentation. Honestly, at the time, I went for the free food but I left inspired and itching to do something. The patient who presented was this woman:

Linda Kenney

Mrs. Kenney was a victim of a medical error. She had an incredible story about what happened and how she channeled her frustration regarding the event to creating an organization called MITSS or Medically Induced Trauma Support Services. Here’s her story from the website:

My name is Linda Kenney and I am a survivor of a medically induced trauma. In November of 1999, at the age of thirty seven, I underwent surgery for a total ankle replacement at a major medical facility in Boston, Massachusetts. Instead of waking up with a new ankle, I awoke several days later to find out the nerve block had been accidentally delivered to my heart and I had gone into full cardiac arrest. Emergency open heart surgery was performed to restart my heart and at that point there was a 50/50 chance I would make it through the night. This incident has had a profound effect on myself, my family and all those involved.

The anesthesiologist reached out to me right away and in time we came to an understanding, a peace and a friendship. The hospital itself was another matter. I made several attempts to contact the hospital seeking support or other patients with similar circumstances and my calls were never returned. I am committed to ensure that support exists for other patients.

I am committed to alerting hospital administrators and staff of the need to follow up and support patients, families and hospital staff after a trauma occurs. Support is crucial to facilitate recovery. MITSS has been founded specifically to provide a network that links those involved with resources that provide and promote healing through a variety of media.

When I heard her story, I was blown away. Here I was, about to finish undergrad and enter medical school…and enter a profession I thought would help people, not harm them. The only encounter I had with patients experiencing medical errors was from seeing commercials from lawyers such as Jim Sokolove – patients who were clearly unreasonable and just wanted to rack up money from malpractice.

When I looked more into medical errors, I found that the statistics were staggering – 98,000 deaths in the United States due to preventable medical errors. That’s equivalent to a plane full of passengers falling out of the sky every day. Another 100,000 patients become permanently disabled due to preventable medical errors. I started to wonder if I was going into a profession where it was inevitable that I would hurt someone. How could I as a potential medical student change the system so that this didn’t happen?

I then learned about the Institute for Healthcare Improvement Open School, American College of American Quality, and other organizations that offered resources for students to become involved in building a system that would be safer and ensure quality healthcare.

This year at Brown we’re hosting an amazing conference to bring these resources to students and to provide mentorship from people who have been working on specific patient safety projects. I invite you all to come to the Northeast Regional Patient Safety and Quality Improvement Conference on February 5th at Rhode Island Hospital:

February 5, 2011 8:00 – 5:00 PM Rhode Island Hospital – George Auditorium
593 Eddy Street, Providence, RI 02903 (map)
Registration for NE Region PS/QI Conference

Each year, 100,000 patients die of preventable medical errors. As the burgeoning generation of healthcare professionals, it is our responsibility to ensure quality and safe medical care.

Join other students and residents from around the northeast region in a series of interactive workshops to learn about patient safety and quality improvement. Workshop topics include healthcare policy, medication errors, root-cause-analysis with real case studies, the WHO Safe Surgery Checklist, and more.

Through the conference, participants will acquire tools they need to start quality improvement projects at their institutions and will be directed to resources such as the Institute of Healthcare Improvement and American College of Medical Quality.

Free to everyone! Breakfast and lunch included.
Facebook event link

Rhode Island Hospital – George Auditorium
593 Eddy Street, Providence, RI 02903

Featured speakers include:

Linda Kenney
Medically Induced Trauma Support Services

Meredith Rosenthal, Ph.D.
Associate Professor of Health Economics Policy
Harvard School of Public Health

David Lindquist, MD
Clinical Assistant Professor of Emergency Medicine
Warren Alpert Medical School of Brown University

Gordon Schiff, MD
Associate Director of Center of Patient Safety Research
Harvard Medical School
Brigham and Women’s Hospital

Mary Reich Cooper, MD, JD
Senior Vice President and Chief Quality Officer
Lifespan Coorporation

H. John Keimig, MHA, FACHE
President and CEO
Quality Partners of Rhode Island

Joseph Couto, PharmD, MBA
Assistant Professor
Jefferson School of Population Health

Shawn Rangel, MD, MSCE
Staff Surgeon – Department of Surgery
Children’s Hospital Boston

Thomas Miner, MD
Associate Residency Director for General Surgery
Warren Alpert SOM at Brown University

Check out our amazing schedule as well:
NE Regional PSQI Schedule

I hope whoever is in the area reading this can come and attend. It is up to us, patients and providers, to ensure the most basic right in healthcare – safety. By attending this conference, you can take the first step to ensure “do no harm”.

IHI National Forum!

Posted in Patient Quality and Safety by reshmagar on December 4, 2010

Tomorrow I head to Orlando for the IHI National Forum!

Some pre-reading before the conference: A recent study published in NEJM which looked at 10 North Carolina hospitals form 2002 to 2007 showed that harm to patients was common and that the number of medical errors did not decrease over time.

The New York Times published an article citing this study which you can read here: Study Finds No Progress in Safety at Hospitals

Key points from article:

“It is one of the most rigorous efforts to collect data about patient safety since a landmark report in 1999 found that medical mistakes caused as many as 98,000 deaths and more than one million injuries a year in the United States.”

“Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.”

‘“We need a monitoring system that is mandatory,” he said. “There has to be some mechanism for federal-level reporting, where hospitals across the country are held to it.”’

At the conference this weekend, there will be a host of amazing speakers such as Dr. Don Berwick, Dr. Atul Gawande, and Paul Levy, CEO of BIDMC who wrote this in response to the North Carolina study results in his blog:

Painfully slow
Posted: 26 Nov 2010 05:19 PM PST
You can already imagine the responses. “That’s just in North Carolina.” “Our patients are sicker.” “There are problems with the data.”

What would prompt that? This New York Times article, citing a forthcoming NEJM study about medical errors in North Carolina. Here’s the lede:
Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

Other excerpts:
Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems.

. . . The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

And another:
Dr. [Bob] Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Exactly right, Bob! What does it take to motivate this profession? What does it take to make process improvement part of medical school and residency training programs.

Painfully slow, and painful or worse to patients.

If only we had CEOs of hospitals around the country who share the same sense of urgency regarding this issue…

Not quite the same checklist.

Posted in Doctoring, Patient Quality and Safety by reshmagar on August 31, 2010

Last Thursday, we began our Doctoring course starting with a 2nd year orientation to what we would learn this year – the complete physical exam, counseling in difficult topics, and the underlying clinical reasons behind why we ask people to move in funny ways other than to giggle a little inside (…just kidding…sorta). I was overjoyed when our Doctoring course leader brought up my favorite topic – checklists! And more specifically. Dr. Gawande’s book, the Checklist Manifesto which she got about to reading this summer. She decided to use Dr. Gawande’s book and words as an analogy to our Doctoring course.

But she did it the wrong way.

Which made me terribly sad.

Yes, we do use checklists in our Doctoring course. Very very expansive checklists. One for taking a history, separated into its respective parts of Chief Complaint, History of Present Illness, Past Medical History, Family History, etc. There are several more for each part of the physical exam as well. These checklists help us better organize and memorize what we need to go through to get the complete picture of the patient and come up with accurate differential diagnoses.

Unlike the Safe Surgery Checklist, however, these are not bedside tools. In fact, the use of these checklists actually counters the message of Dr. Gawande who advocates for physical checklists to serve as concrete reminders to ensure that a patient’s care not become a victim of the physician’s falters in memory. The checklists we have to memorize are not the kind that Dr. Gawande advocates for at all.

That being said, I was happy that our Doctoring course leader mentioned the checklists and Dr. Gawande. She was able to say his name without gushing…which I’ve not yet been able to do.


Posted in Geneva!, Healthcare Reform, Patient Quality and Safety by reshmagar on July 27, 2010

Last night, a co-worker in Patient Safety sent the department a document that was published yesterday by the British government. In the section for the National Patient Safety Agency, the following was written:

Quality and Safety Improvement

3.56 Patient safety is synonymous with improving overall clinical excellence and sits at the heart of the quality agenda. Currently, functions associated with quality and safety improvement are distributed across a number of arm’s-length bodies as well as elsewhere in the health and social care system. This creates complexity and there is still some way to go to embed improvement fully across the NHS.

3.57 In future, the NHS Commissioning Board will provide national leadership on commissioning for quality improvement and we propose that some essential functions supporting this role from the National
Patient Safety Agency and the NHS Institute for Innovation and Improvement should be brought together within the mainstream work of the NHS Commissioning Board to exploit the leverage that commissioning would provide in placing quality and safety at the heart of patient care.

This doesn’t make sense to me…shouldn’t quality improvement and patient safety be in all sectors of health care?

3.60 We propose to abolish the National Patient Safety Agency. Some National Patient Safety Agency functions will become part of the remit of the NHS Board, while others will be supported to continue in other ways. The following functions will transfer to elsewhere in the wider health system:

Second disappointing news item from yesterday was the conclusion of the first Khmer Rouge trial. Comrade Duch was given a sentence of 19 years for the heinous crimes he committed against his own people. I personally think he deserves a life sentence.

Check out the article about the trial: Anger in Cambodia Over Khmer Rouge Sentence

And then today, Don Berwick, new CMS leader and quality improvement innovator extraordinaire is getting hits from Republicans. Already?!?

New Health Official Faces Hostility in Senate

But luckily I have some pretty pictures from Budapest to cheer me up. I would put up more except:
1. I can’t find my USB cord…it’s somewhere in my room…
2. I am le tired.

Photos courtesy of Bryan Yeh

Articles of the Week!

Posted in Geneva!, Health Rights, Patient Quality and Safety by reshmagar on July 20, 2010

So I just came back from Paris (which was absolutely beautiful and wonderful – pictures soon!) to find an article in my inbox from my best friend from home who thought of me when he read it. The article is interesting and timely to my blog as I recently put up a post (read here: Comments on DG and Intern Day) about some criticisms of Margaret Chan, the Director General and WHO and her comments about the North Korean health care system.

Check it out:

WHO criticizes Amnesty report into NKorea health


Courtesy of Globe and Mail

GENEVA — The World Health Organization found itself Friday in the strange position of defending North Korea’s health care system from an Amnesty International report, three months after WHO’s director described medicine in the totalitarian state as the envy of the developing world.

WHO spokesman Paul Garwood insisted he wasn’t criticizing Amnesty’s work, but the public relations flap illustrated an essential quandary for aid groups in unfree states: how to help innocent people without playing into the hands of their leaders.

Amnesty’s report on Thursday described North Korea’s health care system in shambles, with doctors sometimes performing amputations without anesthesia and working by candlelight in hospitals lacking essential medicine, heat and power. It also raised questions about whether coverage is universal as it — and WHO — claimed, noting most interviewees said they or a family member had given doctors cigarettes, alcohol or money to receive medical care. And those without any of these reported that they could get no health assistance at all.

Garwood said Thursday’s report by Amnesty was mainly anecdotal, with stories dating back to 2001, and not up to the U.N. agency’s scientific approach to evaluating health care.

“All the facts are from people who aren’t in the country,” Garwood told reporters in Geneva. “There’s no science in the research.”

The issue is sensitive for WHO because its director-general, Margaret Chan, praised the communist country after a visit in April and described its health care as the “envy” of most developing nations.

Major global relief agencies have been quietly fighting for years to save the lives of impoverished and malnourished North Koreans, even as the country’s go-it-alone government joined the exclusive club of nuclear weapons powers and wasted millions on confrontational military programs.

Some groups may fear being expelled from the country if they are openly critical of Pyongyang, which is highly sensitive to outside criticism. Still, Chan’s comments were uncommonly ebullient.

Garwood and WHO spokeswoman Fadela Chaib insisted that Amnesty’s report was complementary to their boss’ observations, and sought to downplay Chan’s praise for North Korea. Instead, they focused on the challenges she outlined for North Korea, from poor infrastructure and equipment to malnutrition and an inadequate supply of medicines.

But whereas Chan had noted that North Korea “has no lack of doctors and nurses,” Amnesty said some people had to walk two hours to get to a hospital for surgery. Chan cited the government’s “notable public health achievements,” while Amnesty said health care remained at a low level or was “progressively getting worse.”

Asked Friday what countries were envious of North Korea’s health, Chaib said she couldn’t name any. But she highlighted the importance of maintaining the health body’s presence in the country, where officials do their best to save lives despite “persisting challenges.”

“We are an organization dealing with member states, and we respect the sovereignty of all countries,” Chaib said. “We need to work there to improve the lives of people.”

Sam Zarifi, head of Amnesty’s Asia-Pacific program, said the human rights group stood by its findings.

“We certainly have a lot of restrictions in terms of working in North Korea, but we did our best in terms of capturing the information we could verify,” Zarifi said. “We don’t take the WHO’s statements as criticizing or rejecting Amnesty’s findings.”

He said Amnesty had spoken to North Koreans as well as to foreign health care and aid workers, and relied heavily on WHO for information — including the assessment that North Korea spends $1 per person per year on health care, the lowest level in the world.

The U.N. estimates that 8.7 million people need food in North Korea. The country has relied on foreign assistance to feed much of its population since the mid-1990s when its economy was hit by natural disasters and the loss of the regime’s Soviet benefactor.

North Korea, ruled by Kim Jong Il, is routinely described by U.N. and other reports as one of the world’s most repressive regimes.

Garwood said Amnesty’s research added a needed element to understanding health conditions in North Korea, but added that it didn’t even mention recent improvements in the country as the result of a program funded by South Korea and aided by WHO.

The U.N. body claims that maternal mortality has declined by over 20 percent since 2005, and diarrhea cases and deaths in operations have also dropped. It says more than 6,000 doctors and nurses have been trained in emergency obstetric care, newborn care and child illnesses, while clinics have received better material for operations, blood transplants and other medical interventions.

As for Chan’s April claim that “people in the country do not have to worry about a lack of financial resources to access care,” Garwood said hundreds of field missions have been conducted in North Korea.

“None have come back reporting the kinds of things in the Amnesty report in terms of payment for services,” he said.

“I’m not saying they’re not credible accounts,” he added. “But it’s not taking into account some of the things that are happening today.”

Zarifi, of Amnesty, said the whole debate would be ended if North Korea’s government provided access to monitors so that everyone had a better understanding of the country’s health care system.

“Every indication we have indicates the state of health care in North Korea is dire,” he said.


My supervisor also sent me another article about patient safety which was very interesting and talks of a recent journal article printed in JAMA by Peter Pronovost, the father of medical checklists and specifically, the central line checklist.

Patient safety progress slowed by arrogance of physicians
By Sandra Yin

Despite a decade-long effort to improve patient safety, little progress has been made.

One big obstacle is arrogant physicians who are not held accountable for their actions, says Dr. Peter Pronovost, the quality & safety research group medical director at Johns Hopkins University’s Center for Innovations in Quality Patient Care, in a July 14 article published in the Journal of the American Medical Association.

One personal example Pronovost shares is of a surgeon who made it clear he was not to be questioned. Although the patient had classic signs of a latex allergy, the surgeon refused to change gloves until Pronovost threatened to call a higher authority.

Other examples he describes include physicians who don’t accept that they are fallible. They believe they have all the answers, dismiss team input, or respond aggressively when questioned.

Physicians, he notes, are “overconfident about the quality of care they provide, believing things will go right rather than wrong…thinking they alone have sufficient knowledge and skills to provide care.”

In a healthcare culture that often looks the other way, rather than speaking up about actions that might harm a patient, it’s clear that a lack of accountability is a key challenge. The U.S. healthcare culture doesn’t yet back questioning physician behavior. And that can harm patients.

“Too often, neither physicians nor hospital leaders hold themselves accountable for patient outcomes,” Pronovost writes. Hospital administrators say their patients are too sick and that central line-associated bloodstream infections are inevitable, although they are not. That many hospital CLABSI infection rates are higher than the national average suggests doctors and hospital administrators feel no accountability for them, Pronovost adds.

To read the JAMA article: Pronovost Accountability

Gasp! Someone critiquing Dr. Berwick?!?! (Actually, not really…)

Posted in Patient Quality and Safety by reshmagar on July 13, 2010

Dr. Berwick and That Fabulous Cuban Health Care
The death march of progressive medicine.
Bret Stephens

Heaven forbid that anyone accuse Donald Berwick—lately of Harvard, newly of the Centers for Medicare and Medicaid Services, with $800 billion under management—of being an admirer of Cuba’s health-care system. In the matter of CastroCare, progressives of Dr. Berwick’s stripe are rarely at a loss for superlatives. But suggest that ObamaCare is a step in the Cuban direction, and these same people will accuse you of rank scare-mongering.

We don’t scare-monger in this paper. And for the record, nothing in Dr. Berwick’s published record indicates he has ever praised the Cuban system.

But note that when the health-care bill became law in March, Fidel Castro emerged from semiretirement to praise it as a “miracle.” Note also that Dr. Berwick has made himself notorious by warning of “the darkness of private enterprise,” admitting his “love” for Britain’s socialized National Health Service, and insisting that “excellent health care is by definition redistributional.”

Without imputing a mutuality of views, then, it’s worth noting a certain mutuality of respect. So it’s a good time to check in on the state of the Cuban health-care system. That’s just what Laurie Garrett, a senior fellow at the Council on Foreign Relations, does in the current issue of Foreign Affairs magazine.

Lest anyone mistake Ms. Garrett as a raving opponent of the Cuban system, she praises Cuba for offering “an inspiring, standard-setting vision of government responsibility for the health of its people.” Cuba’s (reported) success in reducing the incidence of child mortality and tropical diseases, she adds, is “laudable.”

Just one problem: The system is in an advanced state of collapse. It is bankrupting the state and driving doctors out of the medical field and the country. Its ostensibly egalitarian nature disguises a radically inegalitarian reality, with a tiny number of well-appointed clinics catering to paying medical tourists and senior Party apparatchiks while most Cubans take their chances in filthy, under-resourced hospitals.

Consider the facts as laid out by Ms. Garrett. There are 73,000 physicians licensed to practice in Cuba. This allows Cuba to boast of having the best doctor-patient ratio in the world, with one doctor for every 170 people, as opposed to one for every 390 in the United States.

Yet reality belies the statistics. Slightly more than half of all Cuban physicians work overseas; taxed by the Cuban state at a 66% rate, many of them wind up defecting. Doctors who remain in the country earn about $25 a month. As a result, Ms. Garrett writes, they often take “jobs as taxi drivers or in hotels,” where they can make better money. As for the quality of the doctors, she notes that very few of those who manage to reach the U.S. can gain accreditation here, partly because of the language barrier, partly because of the “stark differences” in medical training. Typically, they wind up working as nurses.

As for the quality of medical treatment in Cuba, Ms. Garrett reports that hospital patients must arrive with their own syringes, towels and bed sheets. Women avoid gynecological exams “because they fear infection from unhygienic equipment and practices.” Rates of cervical cancer have doubled in the past 25 years as the use of Pap tests has fallen by 30%.

And while Cuba’s admirers love to advertise the country’s low infant mortality rate (at least according to the Castro regime’s dubious self-reporting) the flip-side has been a high rate of maternal mortality. “Most deaths,” Ms. Garrett writes, “occur during delivery or within the next 48 hours and are caused by uterine hemorrhage or postpartum sepsis.”

Sound inviting? The number of ostensibly serious people—Michael Moore not being one of them—who think so is nothing short of astonishing. On a visit to Cuba last October, Margaret Chan, the director general of the World Health Organization, said that Cuba “has the right vision and the right direction. Health is a state policy and state is seen as a right of the people.” In 2005, one prominent New York Times editorialist headlined a column “Health Care? Ask Cuba.” Health care was probably also what former Secretary of State Colin Powell had in mind when he noted that “Castro has done some good things for his people.”

Now, to repeat, Dr. Berwick is nowhere on record endorsing Cuban-style health care. And ObamaCare, with its million flaws, is not CastroCare.

But it remains the case that for all those for whom “free” health care has been, as Teddy Kennedy once put it, the cause of their lives, the Cuban system has been a touchstone—proof, supposedly, that socialized medicine is, as Dr. Berwick has said, the only “just, equitable, civilized and humane” answer when it comes to addressing the dilemmas inherent in health-care delivery.

The truth is that socialism and related forms of command-and-control technocracy work as well in the health-care market as they do in every other. Which is to say, not at all. When better-heeled Americans start flying to offshore medical centers for their facelifts and bypasses (performed by expat American doctors) while poorer folk make do in ObamaCare’s second tier, then perhaps the real lessons of the Cuban system will begin to sink in. Even, perhaps, among Dr. Berwick’s progressive friends.

Patient Safety on a Global Scale

Posted in Health Rights, Patient Quality and Safety by reshmagar on July 12, 2010

Prior to my work at the WHO, I had only been privy to issues in patient safety on a domestic level. In fact, the landmark documents on patient safety and medical errors from the Institute of Medicine primarily includes only statistics from the United States as well as some other developed nations like the United Kingdom for comparison’s sake. The lack of research in patient safety and quality improvement interventions in the developing world is unfortunate and a hindrance in understanding how to improve health systems globally.

The following statistics I borrowed from my supervisor’s recent presentation on patient safety to my summer program:

Adverse Drug Events alone: 8 -10% of hospitalized patients
– Contributing to tens of billions USD to healthcare systems, 140 000 death in US alone
– 28 – 56% of ADEs are preventable

Medical devices (manufacturer-, user-, design-related errors)
– Over 1 million adverse device events / year in US (6.3 events per 1000 patient days)
– Low and middle income countries (LMIC): e.g. 34.2 device related infections per 1000 patient days

Surgery & anaesthesia adverse events
– US: 48% of all events (54 – 74% preventable)
– LMIC: surgical adverse events rates 5 -10 times higher

Nosocomial infections (pneumonia, catheter-related BSI, surgical wound infections)
– 5 – 10% of hospitalized patients (high income)
– 25 – 40% of hospitalized patients (LMIC)

Unsafe blood products (blood transfusion) – HIV, Hepatitis, Chagas, West Nile
– Sub Saharan Africa: 88.5% of blood products not screened for HIV

Misdiagnosis (delayed & erroneous)
– Highly developed countries: 10-15% of diagnosis are incorrect
– Overdiagnosis of Malaria – underdiagnosis of pneumonia – undertreatment
– Lack of timely follow up of important test results (up to 50%)

Unsafe injection practices
– 16 billion injections / year in developing & transitional countries
– Between 40 – 70% with reused needles without sterilization

These statistics have a margin of error simply due to the lack of research and funding for interventions in the developing world. Ironically enough, the major funders of the WHO and other health research organizations in Geneva do not fund health systems research. How can we expect to better global health without looking at healthcare as a whole?

Safety Culture

Posted in Healthcare Reform, Patient Quality and Safety by reshmagar on June 25, 2010

What am I doing over here?

Posted in Geneva!, Patient Quality and Safety by reshmagar on June 24, 2010

Now comes the serious stuff. No pictures of Geneva, or its beautiful buildings or little kids that I sneakily take. I will tell you what I am working on exactly.

Do you remember the first week of college? When you started to meet a ton of people all at once and the conversations and names of everyone pretty much blurred together. You probably had a conversation just like this:

Person 1: Hey. How’s it going? I’m Albert.
Person 2: Hi, I’m good. I’m Beatrice.
Person 1: Cool. Where are you from?
Person 2: Fargo, North Dakota. And you?
Person 1: Oh snap! Like the movie! *laughter* I’m from Macon, Georgia.
Person 2: Nice – I’ve never been to the South. So where are you living?

…etc etc. The same questions. Some variation in answers. A script that you memorize and maybe for kicks change up. Here, all the interns ask the same questions – name, place of origin, place of study, and department you’re working in.

How many times I wished I had this t-shirt during the past week.

I’m working in PSP – Patient Safety Programme. Not a very glamorous department – I am not stopping TB, HIV/AIDS, or other infectious diseases. I am not managing the finances of other healthcare systems. I am not also writing policy briefs for the bigwigs here. My fellow interns are. I am instead in a small, small department. And I love everything about it.

I think it’s hard to gauge what the words “patient safety” mean at the WHO if you’re not a healthcare professional. Definition-wise it’s simple: freedom from accidental injury. In the USA, medical errors are the 8th leading cause of death. This adds $14.6 billion annually in direct healthcare costs. Other countries have staggeringly similar results.

Many of us have heard about the big medical errors – the ones that are caught. Wrong site surgeries. Prescription errors. Someone dying as a result. But those are actually the minority of medical errors. There are countless mistakes being made, most being near-misses and others causing a setback in treatment and an increase in costs.

But it is not the healthcare worker’s fault. Yes, the surgeon might have operated on the wrong leg. But what led to that? Was it the nurse and/or resident that draped the patient incorrectly? Was it the assistant who looked at the scan backwards? Was it the marker that after disinfecting the site washed off? Was it the surgeon who was trying to remember the tricky procedure who failed to notice that this was the wrong side? In healthcare, we call these system failures.

The culture of medicine is an oxymoron of sorts. On one hand, we have a field which is advancing day by day and the players in this field are expected to keep up every second. We are held responsible for people’s lives, needing the knowledge of intricate procedures with sometimes hundreds of steps to obtain the ideal outcome. Yet, we are shunned if we use memory aids or delegate tasks to others. We are expected to just know what to do at the exact right moment. I was once told that the human brain can effectively remember 7 things at a time. That’s a far cry from the standard number of steps even in the most routine procedure.

Ironically though, other industries that are faced with similar high stress situations don’t rely on human memory. In the field of aviation, pilots are penalized for not using memory aids to help them. Pilots use checklists for everything – electronic and paper. Before take-off, the co-pilot goes through the list of things that need to be checked and cleared before even thinking about leaving the strip. Upon take-off, another checklist is used. As Peter Pronovost, developer of the Central Line Checklist states, “their presence as a safety measure contributes to the control of unpredictable human factors.”

Which leads me to what I work on. Can you guess what it is? Yes, checklists. I am working on various aspects of the Checklist project here in PSP. There are 3 checklists the WHO is involved in – Safe Surgery, Trauma Care, and Safe Childbirth Checklists. Right now, I am primarily working on the Trauma Care Checklist but am also doing other projects with Safe Surgery in something that is very important to me, its sustainability as a quality improvement tool.

I will go into details about each checklist in future posts. I mean, I have all summer to do that and FASCINATE you all. But I can tell you why I like working here. I came to the WHO with the intent on working in PSP. Don’t get me wrong. I am interested in infectious disease and its eradication and health systems as well. But I wanted to be apart of a project that was on the ground, that wasn’t heavily involved in politics (although there are plenty regardless), and where I felt I could make an impact in both the patient as well as healthcare worker community. As you might know, I have a passion for quality improvement issues. So not only was this right up my alley, but as an intern, I could do something and maybe, just maybe make things a little better somewhere.

I encourage everyone to check out what my department does: WHO Patient Safety

On another note, today I got my Carte de Legitimacion or in other words, the card that says I have a work permit here at the WHO and in Switzerland. It’s pretty legit. I’ll take a picture and put it up soon.