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Survey Asks Doctors And Patients If Doctor’s Notes Should Be In The EHR

We are fast entering the era of the electronic health record, when it will be possible to call up our medical records on our computers and mobile devices. Medication lists, lab results, appointment schedules—they’ll all be available with clicks of your mouse or taps on the screen of your smartphone or tablet.

But one question that’s far from settled is whether the electronic health record should include the notes that doctors make about them. A doctor’s notes can be straightforward, such as a reminder that an additional test might be needed. But they can also include somewhat speculative observations and hunches about a patient and his or her medical conditions. The Open Notes project is a research program designed to test the consequences of giving patients access to doctors’ notes. Harvard-affiliated Beth Israel Deaconess Medical Center is one of the test sites.

The Open Notes project is far from finished. But results of a survey of the expectations that doctors and patients have for note sharing are being reported in today’s Annals of Internal Medicine.

I don’t think there are any great surprises here.  More than half of the primary care physicians Read more »

*This blog post was originally published at Harvard Health Blog*

Obama’s Going Grey, But Do Presidents Age Faster Than The Rest Of Us?

It’s more than just a few flecks. President Barack Obama, who turned 50 in August, is definitely going gray. He’s said the color change runs in his family and has mentioned a grandfather who turned gray at 29.

But others see it as a sign that the presidency is taking a toll on Obama, as it has other on presidents. Dr. Michael Roizen, of RealAge.com fame, says presidents age twice as fast as normal when they’re in office. The main cause, he says, is “unrequited stress—they don’t have enough friends to mitigate the stress,” which brings to mind the line commonly attributed to Harry Truman: if you want a friend in Washington, get a dog.

Accelerated presidential aging? Not so.

The only problem with this notion of accelerated presidential aging is that it just ain’t so, according to S. Jay Olshansky, a professor at theUniversity ofIllinois at Chicago and a longevity expert. Read more »

*This blog post was originally published at Harvard Health Blog*

Researchers Compile Surprising List Of Most Risky Drugs For Older Americans

Some medications are well known for being risky, especially for older people. Certain antihistamines, barbiturates, muscle relaxants—take too much of them, or take them with certain other medications, and you can wind up in serious trouble (and possibly in the back of ambulance).

But researchers from the federal Centers for Disease Control and Prevention (CDC) and Emory University reported in this week’s New England Journal of Medicine that those high-risk medications are not the ones that most commonly put older Americans (ages 65 and older) in the hospital.

Warfarin is #1

Instead, they found that warfarin is the most common culprit. Warfarin (the brand-name version is called Coumadin) reduces the blood’s tendency to clot. Many older people take it to lower their risk of getting a stroke.

After warfarin, different Read more »

*This blog post was originally published at Harvard Health Blog*

Americans Taking More Antidepressants Than Ever

Remember when the best-selling book Listening to Prozac came out almost 20 years ago?

Now Americans aren’t just reading about Prozac. They are taking it and other antidepressants (Celexa, Effexor, Paxil, Zoloft, to name just a few) in astounding numbers.

According to a report released yesterday by the National Center for Health Statistics (NCHS), the rate of antidepressant use in this country among teens and adults (people ages 12 and older) increased by almost 400% between 1988–1994 and 2005–2008.

The federal government’s health statisticians figure that Read more »

*This blog post was originally published at Harvard Health Blog*

Caring For People In The Later Stages Of Alzheimer’s Disease

Barbara Moscowitz, coordinator of geriatric social work for the Geriatric Medicine Unit at Harvard-affiliated Massachusetts General Hospital, spoke to me and about a dozen other Harvard Medical School employees yesterday as part of series of seminars on family life and other issues offered by the school’s human resources department.

Moscowitz’s talk was titled “Dementia and Cognitive Decline (Aging Gracefully).” I was there mainly out of professional interest because I’ve written a couple of articles for the Harvard Health Letter recently about Alzheimer’s and dementia, including a piece in the September 2011 issue about mild cognitive impairment and another in July 2011 about new Alzheimer’s guidelines.

But I also wonder about how my own aging brain is faring (not well, it seems, on some days) and I have an older parent (age 81).

So my curiosity wasn’t entirely work related.

A disease of behaviors

Moscowitz covered Read more »

*This blog post was originally published at Harvard Health Blog*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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