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Wayne Parsons, an injury attorney at the InjuryBoard.com, has a nice post about the value of keeping a diary. He recommends it to all his clients. He references an article on About.com written by independent journalist Betsy Lee-Frye.

There are actually two kinds of diaries that benefit patients. The first is a diary of the kind Mr. Parsons recommends. You record your condition, symptoms, side effects, medication plan, and etc. It provides good data for you to use when you’re talking to your doctor. For a good article on how diaries like this help you get better treatment, see for example, Use of a structured migraine diary improves patient and physician communication about migraine disability and treatment outcomes published at InterScience or A patient diary as a tool to improve medicine compliance published by SpringerLink.

The other kind of diary is a journal. Instead of recording symptoms and medications, you write about your response to any significant event in your life. Surprisingly, journals have been found to be very therapeutic. The best article I’ve seen summarizing the positive effects of journaling is Baikie & Wilhelm, “Emotional and physical health benefits of expressive writing”, Advances in Psychiatric Treatment vol. 11 (2005): 338-339.

Tim’s Takeaway: Patients would do well to take Wayne’s advice. Even if you don’t know how to write a diary, get started. An easy way is to google patient diary or pain diary. You’ll find lots of forms online.

According to a 2006 pilot study by 4 Italian researchers reported by SpringerLink, mental health workers found relief from burnout by learning to better manage their interpersonal relationships.

…previous findings and a large part of the target group stated that the interpersonal relationship was one of the most important sources of stress at work.

You’ll find a full abstract at the hyperlink above and full text of the study is available through SpringerLink.

The NursingTopics.Blogspot ran copies of two more articles about the looming shortage of nurses.

The first article documents the size of the shortage now estimated to be 1.2 million nurses (700,ooo due to retirement and 500,000 due to rising demand generated by aging baby boomers) by 2014.

The second article chronicles the lengths hospitals and home health centers are going to in order to recruit nurses–including offering $50 gift cards for interviewing and raffling opportunities for vacations.

Headaches from overuse of medications. It’s a problem with a growing global awareness according to a recent article in virtualmedicalcentre.com. “MOH is associated with severe disability, unmet treatment need and little clinical data to support current management strategies.” Left untreated, they can have a bigger impact than migraines. So says David W. Dodick, M.D., Neurology, Mayo Clinic in Arizona.

He was lead researcher on a study on medication overuse headaches (MOH) in eight countries.

The study concludes that the best strategy to address MOH is to prevent overuse of medications through effective physician/patient communication and careful withdrawal of the overused medications.

Tim’s Takeaway: One more piece of the mounting evidence that poor communication between patient and care is at the root of much of patient non-adherence.  Companies that are rolling out patient information should consider whether patients and practitioners are having the kinds of conversations that put that information to good use.

Press Ganey published a white paper this past July 2008 documenting the link between patient satisfaction and medical malpractice risk. Here’s the key paragraph.

In many circumstances the filing of a claim is not due to an injury alone; it is a combination of an injury coupled with a “plus” factor. A plus factor is an aggravating circumstance that prompts a patient to seek a lawyer, such as poor communication, lack of disclosure, anger, or the real need for information. These factors illustrate the lack of a developed relationship between doctor and patient and the importance of patient satisfaction. These are also the same factors that often make a potential case more attractive to an attorney, and certainly impact a jury, when considering an award of damages during a trial.

The paper is filled with good data and lots of citations. Definitely worth your time to read.

Tim’s Takeaway: Here’s more evidence that healthcare is a relationship based industry and we ignore patient experience at our peril.

More and more patients are taking medication for cancer at home. While it’s nice that patients get to go home, it also means more errors with medication.

In a study of 1300 patients reported by Science Daily, 7% of adults and 19% of children had medication errors, often with harm to the patient.

You’ll notice that confusion over orders was a prime contributor to medication errors. The errors for adults included administration of incorrect medication doses due to confusion over conflicting orders. Examples of pediatric errors included parents giving the wrong dose or the wrong number of doses per day of medicines because of a caregiver’s confusion about instructions.

Better communications was cited as a key to alleviating the problem:

“Requiring that medication orders be written on the day of administration, following review of lab results, may be a simple strategy for preventing errors among adults, while most of the errors involving children may have been avoided by better communication and support for parents of children who use chemotherapy medications at home,” said Dr. Walsh.

Here’s a nice bit of detective work done by Dr. Michael Kleerekoper who blogs over at Endocrine Today. He noticed an op ed piece in Sunday’s New York Times that quoted a source saying President-Elect Obama claimed he could save $80B a year by pushing preventive medicine. So, he set out to find examples of ways that preventive medicine could save the patient pain and the healthcare group money by reducing fractures.

He found three cases and lots of money at stake, as much as $9,000 per patient fracture.

The concluding sentence rings familiar with what we’ve seen in other areas of medicine.

Our next priority would seem to be improving patient adherence to therapy that prevents adverse health outcomes but does not make them feel better today. 

Tim’s Takeaway: Dr. Kleerekoper identifies the central challenge. How do we communicate with patients so that they regularly take actions that work only in the long run. It’s not as futile as it might seem. In fact, there are case studies in marketing (Listerine and home security systems come to mind) where companies have had success doing this. It does take creativity though.

We’re a remarkably visual species, aren’t we? Pictures, it turns out, are worth a thousand words. The finding shows up in research about patient diaries - I’ll post some articles here if I can find them and in informed consent.

People simply understand more readily and express themselves more easily using pictures.

Here’s an excerpt from a study quoted in DotMed (http://www.dotmed.com/news/story/7800/).

In this prospective, randomized, controlled study, the diagram method — in which patients viewed a set of diagrams illustrating 12 key points before signing an informed-consent form — was most successful in terms of patient recall of the information and increased the interaction between the physician the patient.

You’ll be hearing more about informed consent in the future. There’s a growing concern that informed consent has morphed from an opportunity to have discussion with patients to a way for physicians to cover themselves legally.

Tim’s Takeaway: Are you exploring ways to communicate with your patients pictorially? It can make your communications much more effective, and not just with patients from diverse backgrounds.

The Tennessean is carrying an article by Dr. William Stead that seems thoughtful and well-intentioned, yet introduces confusion by conflating two important issues: patient non-adherence and medication error. Dr. Stead is associate vice chancellor for strategy and transformation and director of the Informatics Center at Vanderbilt University Medical Center.

He starts the article with some useful and provocative statistics:

Sixty-one percent of patients fear being given the wrong medicine. Over 150 million phone calls requesting clarification from pharmacists to physicians are made annually because of the difficulty in interpreting the prescription.

And then inexplicably puts not medication error, but patient non-aderence at the crux of the problem.

As many as 125,000 die annually from non-adherence to their medications.

Dr. Stead chronicles a careful process he carried out at Vanderbilt to clean up the medication errors. All the while continuing to mix together issues that would be better dealt with separately.

As an example, here’s his critique of e-prescribing:

e-prescribing is better thought of as nine smaller processes — deciding what to prescribe; creating the prescription; transmitting the prescription to the pharmacy; pharmacist-prescriber dialogue; dispensing; filing the claim; taking the medication; monitoring for effect and adverse effect and refilling the prescription.

Notice that the process has a variety of vulnerabilities from a variety of sources. Both deciding what to prescribe as well as the pharmacist-prescriber dialogue are vulnerable to lack of information about other medicines the patient is taking (a medication error). They’re also vulnerable to patients withholding issues about beliefs and lifestyle that could keep them from filling or taking their medicines (nonadherence issues). Transmitting the prescription to the pharmacy is a pure technology issue. Dispensing is open to human error. Monitoring for adverse effects is often hindered by lack of trust between the physican and the patient (a nonadherence issue).

Tim’s Takeaway: Dr. Stead raises important issues. And thanksfully he’s attacking his challenges with a critical eye. If we’re going to get to the bottom of the problems, we’ve got to separate them out according to their root causes. Otherwise, we’ll be dealing with a conceptual tangle.

BBC News’s Jane Dreaper reports on a growing sense in Great Britain that the healthcare system is showing less compassion and patients are paying the price.

The case in point concerns Brigadier John Platt, a recipient of the Distinguished Service Order who led his troops across a river in Italy in WWII. He’s 101 now and was treated with little respect when discharged from from an NHS hospital. In fact, his hearing aid was squashed, he was sent home in his pajamas, his soiled clothing were intermixed with the clean, and the staff lost his teeth.

Needless to say, his grown children were distraught. “I was so furious. I think respect in that situation is the same as compassion,” they said.

Notice the NHS apology:

“Clearly some aspects of Brigadier Platt’s discharge in 2006 were unacceptable and the Trust apologises for any distress that this caused the patient and his family.

“In apologising, the Trust also acknowledges the concerns raised about some of Brigadier Platt’s personal effects.

“The Trust takes all complaints seriously so that it can learn from these experiences.”

In my mind, this borders on the kind of perfunctory apologies that get healthcare groups in trouble. They downplay the injury, don’t really convey compassion, and ring of forced contrition.

The story concludes that burnout is on the rise and a likely culprit.

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