the mess in akron

Sunday, April 9, 2017

The road to the Final Four culminates in a national holiday and it is also an opportunity for many to consider the plight of the student athlete. While their skill allows coaches and colleges to make millions, the players do not share in the bounty and very few will go on to play professionally. A student athlete is bound by the many rules and regulations of the NCAA and often has little recourse should the coach leave, the school be placed on probation or any myriad other issue that might arise.

But it’s not only college athletes who may fall victim to arbitrary rules that are more about money than equity. Consider the situation of emergency medicine residents training at the Summa Health System in Akron, Ohio. Their training program has been placed on probation by the Accreditation Council for Graduate Medical Education (ACGME) and may lose its accreditation on July 1. The residents in the program could transfer to another hospital or university program but unless they are granted their released by Summa, their new employer won’t get paid to teach them and likely would not open up a spot on their “roster.”

Some background about how medical education works. After graduating from medical school, newly minted doctors continue their postgraduate training as residents at teaching hospitals. Depending upon the specialty, that training can last three to seven years or more. Like an apprenticeship, as the doctors gather more experience in caring for patient, they are given more responsibility and less supervision until at the end of their training, they can care for patients independently. In addition to seeing patients, the hospitals are required to have teaching physicians who are responsible for lectures and research to expand the new docs’ knowledge base beyond what was taught in medical school. Medicare funds those residency teaching programs, including resident salaries and hospital expenses associated with their teaching, from the professors to the office support staff. And to be funded, a teaching program needs to be accredited by the ACGME.

The Mess in Akron

In Akron, Summa, a major teaching hospital, underwent an unusual change in their emergency department on January 1. The incumbent group of emergency doctors who had practiced there for 40 years was replaced by another. It wasn’t about the quality of patient care; it was about a contract coming due, a dispute over money and who would be paid what. The hospital announced a hastily arranged bidding process to find a new group of ER doctors, with a request for proposal due on December 29. The incumbent local group was not chosen and a new national company was awarded the contract that began on January 1. Normally, there is a transition period that lasts 3-4 months so that there is minimal disruption to patient care. In Akron, Summa arranged for a new set of docs to start 48 hours after the contract was awarded. Unfortunately for the emergency residents who were caught in the crossfire, the new group did not hit the ground running when it came to teaching and providing academic structure and supervision. On February 8, the ACGME placed the residency program on probation.

In the world of the NCAA, players have little option when a coach leaves or the college changes its promise to a student athlete. The education opportunity may remain, but the opportunity to play or compete may be lost. Perhaps a worse situation now exists for the emergency medicine resident trainees in Akron. There is no guarantee that their program will regain accreditation and if that accreditation does not occur, those same doctors will not be able to take their board exams so that they can call themselves specialists. Training has to occur in an approved, accredited program to count. And yet, if they try to find another place to train, there may not be funds to allow that to happen, because the hospital can, in effect, block the transfer. It sounds a lot like a student athlete wanting to transfer to another college but can’t because they were being blocked by their coach.

Medical students often begin their journey filled with optimism. As they progress through four years of medical school and then more years of postgrad training, it takes a lot of work and emotional capital to maintain a level minimum level of altruism. For those caught in the Akron mess, it is a sad reminder that too often money takes precedence over common sense, and while it’s hard to consider physician as victim, perhaps this might be one time when it is true.

Reference:Annals of Emergency Medicine April 2017

 

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mistakes

Monday, March 20, 2017

There are many lessons to be learned from March Madness, but for the sports fan, there is perhaps nothing worse than watching your team lose a close game and not because of the success of an opponent, but because of a referee’s error. Officiating mistakes happen and are usually forgotten, except when they occur at a pivotal moment late in the game, leaving no opportunity for recovery. From a goaltending call that wasn’t made or a travel not called, to a decision on intentional fouls, each team’s fan base will see the exact same slow motion replay and come away with a different truth. It’s not common for NCAA administration to apologize for an error and by then, both teams have gone home and the damage has been done.

In medicine, mistakes are inevitable and while the individual provider aims for perfection, it really is a pipe dream. The complexity of the human body and the way it is attacked by disease, infection and trauma makes for a moving target when it comes to trying to prevent or fix problems. Once upon a time, medical care was mostly diagnosis driven and while doctors could be elegant in deciding what was wrong, they had few tools to treat the things that they found wrong. It’s only been very recently that medical care moved from comfort to cure, but that move has opened the Pandora’s box of error.

There are a variety of errors that are possible in the care of a patient and they mirror what happens on the basketball court. The care provider, whether a doctor in the office, a paramedic in the field or a nurse at the bedside, has to put themselves in the proper positon to collect information, process it and make a diagnostic decision. This is no different than a referee who have to be in position to watch a play, know the rules and make a call. A diagnosis or call is missed if any steps fails.

In medicine, diagnosis needs the information gathering skills of talking to the patient, asking the right questions and performing a physical examination. If the information is misleading, a wrong test might be ordered, driving the diagnosis and treatment in the wrong direction. A patient with indigestion might actually be complaining of pain from the heart and coronary artery disease. If early in the disease process, the patient ignores the symptoms or the care provider misinterprets the symptoms, the opportunity to avert a heart attack might be lost. On the other hand, the indigestion might be gallbladder disease and if that diagnosis is missed, the patient might develop a major abdominal infection. Or just maybe the indigestion is “just” indigestion and heartburn, caused by the reflux of acid into the esophagus. Miss this diagnosis and treatment and chronic reflux can result in Barrett’s esophagus, changes in its lining, that can be a cancer precursor. And these are just the common causes of heartburn; textbooks are filled with plenty more.

The right diagnosis is no guarantee of making the right call when it comes to treatment. While there are guidelines for many situations just like a sports rulebook that lay out the call for most situations. However, it’s hard to know or remember every single nuance, especially when time is of the essence and there are some situations where the rules just don’t apply. There may times at the bedside where decisions have to be made and there are no “best “options. Even if there are, no guarantee exists that picking the right treatment will result in a positive result. A bad outcome does not mean that a mistake was made, and sometimes a mistake happens and doesn’t cause harm.

Mistakes happen in medicine happen but most go unrecognized or unreported; the no harm no foul rule. But medical systems are learning that a near miss is a learning opportunity, to make certain “minor” misses don’t become major disasters. The concept of whistleblowing is encouraged to look for ways to improve and in this way, it becomes the medical equivalent of instant replay. The reporting systems also help sort out what happened when major errors occur and the patient is injured and it often takes a disaster for a system to change.

College basketball may be life and death for some fans and their happiness may depend upon a referee’s call. Some of their mistakes are fixable and can be reversed by instant replay but in many cases, there is only an apology that is issued well after the fans have gone home. Who knew that the same situation exists in medicine. The life, death, happiness paradigm is literally true when it comes to medicine. Mistakes happen and many can be overcome but sometimes all that can be offered is an apology.

 

Images: NY Post, WCRBtv.com

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