Monday, August 8, 2011

Routine Gun Inquiry Is Off Limits for Doctors in Florida -

As a primary care physician, I regularly ask patients questions that many people would consider rude, inappropriately nosy or just irrelevant in polite conversation.

Do you wear your seat belt? How much alcohol do you usually drink? Do you use recreational drugs? Have you ever injected yourself with anything? Do you have sexual relations, and if so, with men, women or both?

Questions like these have long been a standard part of medical interviewing, and for good reason. The answers may reveal clues about a person's symptoms or physical findings on exam. If a person says he or she drinks heavily or has used intravenous drugs, I may be more alert to signs of liver problems when doing the physical exam and more inclined to order certain blood tests. The answers also help me know if the patient is at greater risk for common, yet preventable, causes of death, like H.I.V., car accidents and heart disease, so that I can counsel him or her.

There's one customary question, though, that I'm no longer allowed to ask. In June, Gov. Rick Scott signed a law barring Florida doctors from routinely asking patients if they own a gun. The law also authorizes patients to report doctors for "unnecessarily harassing" them about gun ownership and makes it illegal to routinely document firearm ownership information in a patient's medical record. Other state legislatures have considered similar proposals, but Florida is the first to enact such a law.

The law provides an exemption if the question is "relevant to the patient's medical care or safety," though it doesn't specify what would qualify as relevant. Penalties for violating the law include disciplinary action by the Florida Board of Medicine, which could include citations, fines and "remedial education."

The measure was introduced in the state Legislature after a pediatrician in Central Florida dismissed a mother from his practice when she angrily refused to answer a routine question about whether she kept a gun in her house. The doctor, Chris Okonkwo, said at the time that he asked so he could offer appropriate safety advice, just as he customarily asks parents if they have a swimming pool and teenagers if they use their cellphones when they drive. He said that he dismissed the mother because he felt they could not establish a trusting doctor-patient relationship.

Advocates of gun rights argue that routine questions about firearms violate their privacy, make them vulnerable to discrimination by insurance companies and the government, and "offend common decency," as Marion Hammer, a former president of the National Rifle Association who lobbied for passage of the bill, put it in letters to N.R.A. members. Ms. Hammer said that gun-owning parents had complained to her for many years about pediatricians' inquiries, which she believes are ineffective at preventing gun injuries.

She contends that such inquiries are part of a political antigun agenda by the American Academy of Pediatrics.

"You don't go to a doctor to be interrogated or intimidated," she said. "There's a clear line between violating privacy rights and imparting safety information."

The A. A. P. takes the position that guns are a public health issue and that pediatricians have a duty to ask about ownership because firearm injuries affect a large number of their patients. According to the group, firearms account for a third of all deaths from injury among teenagers and more than one in five deaths from injury among people ages 1 to 19.

The academy recommends that parents not have a gun in the home. When guns are present, it suggests they be kept unloaded, in a secure, locked place, with the bullets stored separately.

"There's no political agenda — we're talking about the safety of children," said Dr. Lisa A. Cosgrove, president of the group's Florida chapter. "The best way to protect them is to teach the parents how to protect them."

Because the new law directly conflicts with accepted medical practices, some of my pediatrician colleagues have told me privately that they worry that not asking about firearms could put them at risk of a malpractice claim if the patient subsequently dies of or is injured by a gunshot. Psychiatrists routinely inquire about guns, too, and the law's requirements potentially place them in a legal predicament.

As a general internist in South Florida, I often see the effects of gun violence. Many of my patients have been injured or disabled by a gunshot, or had a family member shot and killed. Shortly after the new law went into effect, local television stations broadcast a story about a 4-year-old in Miami who was accidentally shot by his 17-year-old half brother, who was playing with a .22-caliber rifle.

The Florida chapters of the A. A. P., the American Academy of Family Physicians and the American College of Physicians have filed a suit contesting the law as a violation of the First Amendment right to free speech. (Disclosure: I am a member of the A. C. P., the major professional organization for internists, but am not involved with the litigation.) The suit, which calls the gun inquiry rule a "gag law," contends that prevention is a cornerstone of medical practice and that free discussions are key to the doctor-patient relationship and are protected by federal privacy rules.

At the moment, however, those of us working in a clinic or hospital will have to imagine we live in a place where gun injuries aren't a public health issue and forget some of the questions we learned to ask in medical school. In doctors' offices in Florida, prevention has its limits.

Sunday, August 7, 2011

The Medical Practice Manager's Blog| Manage My

My name is Mary Pat Whaley and since 2008, my blog has provided healthcare managers, executives and providers the resources and information they need to drive excellence in their organizations. My background is 25+ years managing physician practices of all sizes and specialties in the private and public sectors. I am Board Certified in Medical Practice Management and a Fellow in the American College of Medical Practice Executives.

Female physicians on Twitter -

I delivered a keynote presentation a few weeks ago entitled "Personalized Medicine: Tailoring Healthcare in the Information Age" to a group of parents who had taken their kids to the Bristol-Myers Squibb Science Horizons summer science camp.

Aside from the jolt the parents received from my presentation regarding anticipated changes in 21st century healthcare, especially involving the myriad ELSI issues that would confront medical practices as a result of the completion of the human genome project, I had made a major point about the extraordinary contribution of social media to today's healthcare system. Specifically, I mentioned how today's patients are becoming more engaged and empowered, and doctors not only needed to be aware of this, but ideally, would become active participants in social media themselves.

Reasons behind such a perspective have been sufficiently summarized by Barbara Ficarra, RN, in a recently contributed article to the Huffington Post.

Among the parents in attendance at the Science Horizons event were two female physicians, both pediatricians, sitting near the front row. They commented to me personally, after my talk that physicians, by and large, do not have time to participate in social media, particularly female docs, and especially those having child-rearing responsiblities.

That conversation prompted the question of how commonplace an occurrence it was for docs to engage in social media, particularly female docs? I have had many Twitter exchanges with various female docs, but naming a group of individuals on the spur of the moment was more challenging. To this end, I deemed it advantageous to specifically identify various female physicians engaged in social media, creating a short list that could be made readily available in a situation like that above.

To generate such a list expediently, I was aware of another list available called Twitter Doctors, created by Hisham Rana, MD (@hrana on Twitter), which allowed a convenient method of collecting names. This list happens to be based on real-time online social influence via a web-based program called PeerIndex. PeerIndex provides a rank number based on certain metrics involving social media performance, analogous to other social media ranking systems (e.g. Klout). Metrics for measuring social influence is problematic, however, and social influence changes over time (dependent on real-time social media engagement). Here, I wish to focus solely on female physicians pre-determined to have a social media presence in mid-2011.

That said, below is a list of female docs who are currently engaged in social media, at least via Twitter, and in many instances, through other social media channels, including blogs. In each case their respective Twitter handle is provided for easy reference (often, additional information, such as a blog link, can be obtained by visiting the respective Twitter page). I ceased collecting names upon reaching 25 total. My goal wasn't to list all female docs who use social media, but to provide a sufficient number of examples for others to follow, and enough to indicate that female docs using social media are indeed not a rare species. The order shown provides no indication of either personal or professional qualification.


Salvaging Medical Cast-Offs to Save Lives -

When Dr. Bruce Charash arrived in Cotonou, Benin, in May 2007, he went from the airport to Hubert Maga Hospital.  Charash is the founder of a Brooklyn-based organization called Doc2Dock, which collects surplus medical equipment from hospitals in the United States and ships it to hospitals in poor countries.  As Charash's plane was landing, a container of medical equipment and supplies had docked, destined for Hubert Maga.
At the hospital, patients were lying on the floor. The entire hospital had one stethoscope.  There was no soap.  Every patient getting blood drawn shared the same needle. In the pediatric ward, there was a little boy, perhaps 4 or 5 years old, lying in bed with blank eyes.  He had  cerebral malaria.   The hospital had bottles and bottles of a medicine, donated by the United States., that could save him.  But the boy could not take it, because Hubert Maga Hospital had no intravenous  lines.

As Charash was touring the hospital, the container of supplies arrived.  People unloaded an anesthesia machine, exam table, C.P.U. monitor, two pediatric dentists' chairs, hundreds of boxes of medical instruments, surgical kits, syringes, gauze, gloves, sutures ― and IV lines, about 5000 of them.   The boxes were ripped open and IV lines rushed to the pediatric ward.
Two days later, a healthy little boy went home.
Every year, hospitals in America throw away thousands of tons of usable medical supplies and equipment — by some measures 7,000 tons a year, a value of $20 billion.   The 2006 model ultrasound machine is sent to a landfill because the 2011 model has arrived.   Unopened, sterile packages of supplies are thrown away because they were marked for one patient's surgery and hospital regulations prohibit their use by another.
Yet every year, hospitals in developing countries around the world turn away patients or provide substandard care because they lack even the most basic medical equipment.
For many problems in the world, a solution already exists — somewhere else.  In those cases, what's needed is a way to connect supply with demand.   Sometimes it's buyers and sellers — potential customers in wealthy countries are interested in the jewelry and crafts made by indigenous artisans; the Worldstock market at is one way to bring the two together.  It can be lenders and borrowers —, for example, connects people with small amounts of money who want to make microloans with people who need, say, $100 to buy chicken feed in Uganda.  Last week's Fixes columns by David Bornstein showed the value of a systematic way to connect social services to those who need them. In a familiar version of the model used by Doc2Dock, food banks collect usable surplus food from restaurants and banquets and deliver it to pantries for the hungry.  In fact, A.B. Short, the co-founder and chief executive  of MedShare, one of the largest of the surplus medical supply groups, used to work for the Atlanta Community Food Bank.
Often what's required is just to move money or information.   That's relatively easy.   It's a much bigger challenge to get a mammography machine no longer needed by a hospital in Atlanta to a hospital in Ecuador.   You have to collect the equipment, check to make sure it's in good condition, store it somewhere, pack it into a container and put it on a boat, get it through customs when it arrives and ship it by truck to the hospital.   You also have to make sure the hospital needs a mammography machine, enjoys consistent electricity and has personnel trained to use the machine.
Doc2Dock is one of several organizations that do this work.  The biggest ones are Project C.U.R.E. in Denver (with whom Doc2Dock often works) and MedShare, based in a suburb of Atlanta, which has shipped 696 containers to 87 countries and territories.  Doc2Dock, one of the newer groups, was started largely with the personal savings of Charash, who had been the director of the cardiac care unit at Lenox Hill Hospital in Manhattan.  It sent its first shipment, to Agogo Presbyterian Hospital in Ghana, in September, 2006, and has now shipped 40 containers to 13 countries.  It is the major organization collecting from hospitals in New York City, the country's biggest hospital market.
There is plenty of room for growth.  Only a small percentage of hospitals have some organized way to deal with surplus equipment and supplies.   Donating surplus goods is intrinsically attractive to hospitals — and it reduces the tonnage they must send to landfills.
Hospitals are not the only ones who donate.  MedShare gets 65 percent of its cargo from manufacturers or distributors of medical equipment and supplies.   A small puncture in a carton may mean that a box can't be shipped to a paying customer, even if the supplies are still individually wrapped and sterile.
The surplus supply groups collect the donations at a central warehouse, where armies of volunteers — sometimes classes of high school students — sort and pack them.  They are bar coded and stored.    Doc2Dock has only a small warehouse in New York, but Wal-Mart picks up the cost of shipping the rest to its warehouses in Tennessee and stores it there.  The supplies and equipment are packed in a 40-foot container.  A typical container from Doc2Dock would carry 12 hospital beds, two delivery tables, an operating room table, anesthesia machine and 800 boxes of supplies such as syringes, IV fluid and lines, gauze and gloves.   Sonogram machines for prenatal care are a frequent request, as are anesthesia units.
The groups find recipient hospitals and learn what these hospitals need by sending staff to visit, or they rely on a trusted nongovernmental organization in that country to make the visit.
The visitors check for dependable electricity and doctors and nurses who are trained to use the equipment.  They look at the hospital's equipment and talk to staff about their wish list.MedShare even has an online catalog of its inventory for hospitals to order from.
Most groups like to develop repeat customers. MedShare is a regular supplier for the network of surgical hospitals for children with disabilities in Africa run byCURE international.  Mark Bush, chief operating officer of CURE, said that its network of 11 hospitals receives about 10 to 12 containers a year from various organizations.  MedShare, he said, does the best job of sending exactly what CURE needs.   The shipments save CURE several million dollars a year, and allow it to get more sophisticated equipment than it would otherwise buy –making possible  more and more advanced surgeries.
One issue that rarely comes up is lack of training —  even in the poorest countries, doctors and nurses  study on modern equipment, and are eager to get a chance to use it.    Charash was in Ghana to see the arrival of a sonogram machine at Tapa District Hospital.  The hospital needed one so badly that the community had taken up a collection, a nickel at a time, to buy one — a process that would have taken 10 years to produce a machine.  When the container arrived in 2008, the machine was the first thing unloaded.   Doc2Dock videotaped Dr. Isaac Boateng, the hospital's chief medical officer and only gynecologist, as he used it for the first time.   "That is the spine on the fetus … there is the head … we know we are not dealing with a breech presentation," he murmured as he ran the probe over the belly of Abigail Kuffour. "The guy looked like he could have been chief of OB-GYN at Johns Hopkins," said Charash.
Sending needed surplus medical supplies to poor countries is an elegant concept.  But it is not the antidote for the barren conditions of many third-world hospitals.   It is a piecemeal solution, covering a tiny percentage of hospitals that need it — and a temporary reprieve even for the hospitals that are reached.   Supplies run out.  Machines break — and most will have very little chance of being repaired.   On Wednesday, I'll respond to comments, and write about how the surplus medical supply groups are grappling with these problems.