Sunday, November 21, 2010

Is Facebook healthy for the doctor-patient relationship? | Booster Shots | Los Angeles Times

If you're on Facebook, you've likely faced this dilemma: Someone you know through your work has asked to become your online friend. You don't want to be rude and say no, but you're also a bit queasy about giving professional acquaintances full access to your personal life online. What should you do?

Dr. Sachin H. Jain encountered this problem in his second week of internship, when a woman whose baby he helped deliver as a medical student asked to become his Facebook friend. As he writes in this week's New England Journal of Medicine, he was wary of allowing his former patient to see his list of friends, view his photos or read his personal blog. On the other hand, he didn't want to be a jerk.

"The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium," he writes.

What could go wrong? Plenty, he speculates.

Patients could call a doctor's medical judgment into question after viewing Facebook photos of a festive holiday party that involved a bit too much spiked eggnog. Or a physician who lists herself as "single" on her Facebook profile could find herself being asked out by patients who probably wouldn't have inquired about her relationship status in person. Or a nurse might blow off steam by blogging about a difficult patient without remembering that she had friended one of the patient's relatives, who would have access to all the gory details. These are some of the reasons medical schools now advise students to think twice about what they post on social networking sites such as Facebook and MySpace.

But without Facebook, a grassroots group called Doctors for Obama might not have persuaded thousands of physicians to flood Barack Obama's campaign with their ideas about health policy during the 2008 presidential election. "This group of physicians continues to have a voice in the Obama administration, largely on the strength of its Facebook-created network of members," Jain writes.

So how did he handle his patient's request? He accepted, partly because he was curious to see how her baby was doing.

It turned out the patient did have an ulterior motive – she was thinking about applying to med school herself. Jain said he was happy to dispense advice, because that was in keeping with the doctor-patient relationship. Among his suggestions: Be careful about how you manage your online identity.

The article is also available via the New England Journal of Medicine's own Facebook page.

Giving Nurses a Leading Role in the Future of Health Care -

At the start of my surgical training, I helped to care for a middle-aged patient who was struggling to recuperate from a major operation on his aorta, the body's central artery, and the blood vessels to his legs. As the days wore on, the surgeon in charge began consulting various experts until the once spare patient file became weighted down with the notes and suggestions of a whole roster of specialists.

The patient eventually recovered, thanks to the efforts of many. Nonetheless, one afternoon while walking around the wards with the senior surgeon, I couldn't help but make a crack about the sheer heft of the patient's chart; it was, after all, my job to carry it around while she visited with patients.

"Remember this for when you get out into the real world," she said, taking the chart from me and letting it dip in a way that exaggerated its bulk. "When the ship seems to be going down, you've got to get all hands on deck."

We might do well to remember that surgeon's advice right now.

As we inch toward 2014, the year that the Patient Protection and Affordable Care Act, the centerpiece of the health care overhaul, takes effect, it has become increasingly clear that the ship known as our health care system is in the process of sinking. And it is not spiraling costs or an overreliance on technology that is weighing most heavily on the health care system, but the sheer volume of patients it must serve.

Currently overloaded with a rapidly aging patient population and their attendant complex medical problems, the system has yet to absorb the 32 million newly insured patients on the horizon. Moreover, over the next 10 years, a third of current physicians will retire, and the physician deficit will increase from just over 7,000 to almost 100,000, with shortages in all specialties, and not just primary care.

But like crew members frantically moving deck chairs, policy makers, medical center administrators, third-party payers and even doctors and patients have remained focused on one thing: the physicians. In all the discussions about adjusting the number of medical schools and training slots, rearranging physician payment schedules and reorganizing practice models, one group of providers has been conspicuously missing.

The nurses.

Nurses currently form the largest sector of health care providers, with more than three million currently registered; but few have led or even been involved in the formal policy discussions regarding the future care of patients. To address this discrepancy, the Institute of Medicine and the Robert Wood Johnson Foundation assembled a national panel of health care experts that has been meeting for the last two years to discuss the role of nurses in transforming the current health care system. Their final report was published last month with no less ambitious a title than "The Future of Nursing: Leading Change, Advancing Health."

The report, it turns out, lives up to its name. Free of the kind of diatribes that usually creep into discussions about the roles of different health care providers, this report instead relies heavily on the evidence amassed over the last 50 years in clinical trials on the efficacy of nursing care. Weighing in at almost 600 pages, it offers several recommendations, including what amounts to a rebuke of the current piecemeal education of nurses and a debunking of the notion that physicians are the only ones who should lead (and be reimbursed for) any changes in the current health care system.

Leaders in nursing have welcomed the report. "I think it's a good blueprint for the future," said Catherine L. Gilliss, president of the American Academy of Nursing, who was not a member of the panel.

Part of that blueprint includes innovative nursing-led services like the Transitional Care Model program at the University of Pennsylvania in Philadelphia, where nurses are assigned to elderly hospitalized patients deemed to be at high risk for relapse. For up to three months after discharge, the nurse makes home visits, accompanies the patient to doctors' offices and collaborates with the primary care physician and family caregivers. In early trials, the program has significantly decreased hospital readmissions and costs by as much as $5,000 per patient. But because not all third-party payers and institutions are willing to enroll patients in a nurse-directed program or pay for new nursing services, not all patients who are eligible for the special care can enroll because they won't be reimbursed.

"What is fundamentally operating here is the culture of care," said Mary D. Naylor, a principal investigator in the Transitional Care Model program and a professor of nursing at the University of Pennsylvania. "We don't recognize how critically important it is to maximize the contributions of everyone."

But the report was just as forceful in urging nurses to revamp the way they are educated, citing the decades-long struggle within the profession to define what exactly a nurse is. The term "registered nurse" can refer equally to graduates of two-year associate's programs, four-year baccalaureate programs, and advanced master's or doctorate programs. In addition to proposing the addition of postgraduate clinical training, or residency, programs, similar to what physicians currently go through, the panel recommended increasing the number of nurses with baccalaureate degrees to 80 percent from 50 percent and doubling the number of nurses with doctorate degrees over the next 10 years.

The expert panel is scheduled to convene again at the end of this month, this time to discuss implementing their recommendations. They will have their work cut out for them. Critics like theAmerican Medical Association have charged that the report overlooks the extensive education and training of physicians and ignores the importance of physician-led teams in ensuring patient safety. In its official statement, the AMA warns that "with a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage."

Whatever the final outcome, leaders in the nursing community believe that the report is an important first step toward organizing nurses to better serve patients through the challenges of the next few decades.

"I don't think any group has a lock on advocacy," Dr. Gilliss said, "and I don't believe that any one group is restricted from reaching out and being in the patient's world, making home visits, doing a little something out of the ordinary."

"There's a need for many hands," she added, "and this may be nursing's shining moment."