Thanks Ancillary Staff!

Today, I just wanted to briefly discuss the importance of ancillary staff in a hospital system. Sometimes, we forget (yes, even the med students) how important the ancillary staff is within our hospital systems. There are many things about our hospital that surely need some change, improvements, modernization, etc. but one of the really great things about our hospital is the efficiency of our ancillary staff (phlebotomists, respiratory therapists, transport, etc.). I did an away elective in a large, public hospital in NYC (which will go unnamed), and never have I seen such inefficient, and unavailable ancillary services. When I thought our hospital was not great, this made ours look like a gem. Transport was impossible to find (I had to wheel patients down to scans, interventional suites, ultrasound rooms, etc). Blood draws were done every 6 hrs (I believe), and if you needed a blood draw at any other time, a nurse would not do it, it was the MD or student's job to draw the blood. Not that I am opposed to the idea of doing blood draws, but as an intern or a resident, spending an hour or more a day drawing blood is not time well spent. For a medical student, it is a learning experience that I am willing to do, but I also have work that I need to complete in order to complete the requirements of my rotations. At our hospital, the patient's nurse will draw the blood if it is needed at times other than phlebotomy rounds.

Of course, nursing staff can be very varied (from excellent, to awful), but the same can be said about the doctors too. There are also some nurses who will ignore, or even yell at, medical students when we ask them for something. If I ask politely, and it is really something that I cannot do or do not know where to find, would it hurt to be helpful?? I don't think so. That's all I have to say about that really. I think the problem really lies in the type of hospital, institutional funding, and nurse's pay. I can understand how at a private hospital, not only the nurse's but also everyone else, needs to work their hardest in order to make the better pay, and keep their job. At the public hospital, apparently, that's just not the case. So all we (as medical students and residents) can do is just swallow it and deal with it. Either increasing nursing pay, or increasing nursing staff, may help alleviate some of the problems, but quite frankly- I don't know what else can be done in a public hospital where in order to get fired, you'd basically have to intentionally kill someone.

So that's all I have to say about this topic for tonight. I just wanted to remind everyone that next time, you see someone from ancillary staff doing their jobs "behind the scenes"- thank them for a job well done. It makes the hospital run much more like a well oiled machine. And for those poor residents and students in NYC- I feel for you, but then again, I was smart enough to turn down my interview offers for greener pastures :)

Handwashing

So today, I thought I'd vent a little about one of my biggest pet peeves- the LACK of handwashing that I observe all the time. This is not strictly pertaining to the healthcare community, but I'll focus mostly on them, and add a few words for everyone else.

As we all know (or hopefully know), handwashing is one of the BEST ways to prevent spreading infections from one person to the other. Some history "The first progress in combating infection was made by the Hungarian doctor Semmelweiss who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweiss, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths" So, everyone should know that by washing hands between EVERY patient, we can decrease infection rates throughout our patient populations. Hospitals are now trying to track data, educate employees, have signs, etc all of which should help improve handwashing rates- but it seems that we're still not anywhere near 100% compliance. Everytime we walk into a patient room, the FIRST thing that should be done, while saying "hello!" should be handwashing. As a medical student, we must do standardized patient exams (fake clinical encounters with real actors/actresses which are then graded) and as part of the evaluation, you get one check mark for washing your hands before touching the patient. I also have a habit of washing my hands when I exit the room- the way I see it, I've performed a physical exam on the patient, probably have some type of bacteria, virus, fungi, whatever, on my hands, and should take it off right away. Even if my next stop is to the nurses station, I want my hands clean- I definitely don't want to get sick by carrying microbes with me everywhere I go.

Of course, handwashing takes about 30-45 seconds or so. One can also opt for the antimicrobial gels, lotions, creams, etc that also work quickly without having to waste time at a sink, followed by drying hands and wasting paper towels. Of course, those antimicrobial agents are expensive for the hospital when you consider how much would be required if everyone just used those rather than handwashing- but what is the extra expense when you compare it to the cost of ONE line infection that requires the patient to stay and extra 5-7 days, PLUS antibiotics? I'm sure the benefits outweigh the risk in this case.

To further elaborate, I have seen all "fishes of the food chain" not adhere to handwashing rules. That goes for medical students, nursing students, PAs, PTs, nurses, residents, attendings, and chiefs. I am pointing no fingers at any one person, we are all guilty (and I am by no means a saint- I'm sure I've forgotten sometimes as well). The important thing is that we must try to make changes and improve our compliance. Some things that I've seen and/or read about that seem to help are: The VA system has an anti-microbial foam at the entrance to each room- just one dab and you're good to go. Sure- these are somewhat costly, but again, doesn't it seem that the cost would still be less than the cost of increased hospitalization time? I've also seen signs posted around the floors- maybe there needs to be more signs, maybe even signs in the patients rooms, on the doors, chart racks, wherever people would be more likely to see them. I've even read that some hospitals who allow staff to issue "tickets" to people who are caught not washing their hands- these "tickets" must then be signed by their supervisor which would surely not be a good thing.

I don't know which way is the best way, but different measures need to be taken to improve this issue. Surely, there are other ideas floating around somewhere.

As I mentioned before, this does not only apply to healthcare workers. I also see people walking in and out of the bathroom (men's bathroom in my case) who will use the facility, and then walk out without washing their hands. In our microbiology class, I had the pleasure of plating some of that "stuff" from the handles in the bathroom, and let me tell you- it's NOT pretty. I even go the extra mile and have the paper towel ready to go, so that after I wash my hands, I will turn off the faucet WITH the paper towel, and also use the paper towel to open the door. Sure, maybe that's excessive since once I get outside, I touch things again, but hey- better than nothing. People eat at restaurants, leave the establishment without ever washing their hands. Same goes for handling babies, or pets. It's something small to remember, but can make a HUGE impact.

I'll close with this link that has some good information on handwashing and infection rates. Also, it links to some real data that backs up the statements made. Let's all try to improve infection rates one handwash at a time.

$4 prescription plans

Disclaimer: I am in no way affiliated with the companies mentioned below, nor do I receive any kind of reimbursement for endorsing any of their programs.

Ok- so now that's out of the way, I'd like to discuss the $4 Rx plans put in place by Target and Wal-Mart. Although I am definitely not a big fan of the corporate world "big fish eating the little fish", when it comes to medications for our patient population, this is a great plan!

Basically, the premise of this program is that both companies offer certain medications that are available in the generic form as a $4 a month Rx, regardless of insurance plan (or for that matter uninsured), or income levels. I cannot express the number of times I have walked into our clinics, ER, inpatient rooms, etc and taken a patient's history only to realize that many of the times, the reason they are in the hospital is because of medication non-compliance. Although I've never actually performed any statistical data on it, I believe the most common reason I get from my patients for not taking their meds is "doc- I just couldn't afford it". That being said, I do note that many of our patients continue to smoke, drink, chew tobacco, etc. all of which are pretty expensive habits anyway- further decreasing their funds for purchasing medications. Well- now we have a plan that allows our patients to purchase their monthly supply for only $4! We have had other Rx plans available to our patients, long before these plans were available, that allowed them to receive certain medications in a 3 month supply for only $20. Well, with this plan, a 3 month supply still SAVES them $8! Not only do I recommend my patients who do not have insurance to start filling their meds that are available for $4 at either of these two stores (I don't prefer one over the other- as long as they take advantage of the savings), but I also have started to recommend it to my patients who do have insurance, my parents, family friends, etc. Many insurance plans offer copays of $15, $20, or $25 and up for 1 month supplies, when some of these medications are available for $4 regardless of insurance type.

Of course, the downside is some of these medications are older medicines, and new meds in the same class are now in the market with studies backing them up that show better efficacy- but how does better efficacy help a patient who can't afford the medicine in the first place? I'd prefer to put them on the older medicine that they will be able to afford, and improve compliance, and have a SLIGHTLY diminshed efficacy- overall, it still benefits the patient more than not taking any medicine.

So what did I do last month while I did an inpatient rotation?? I carried a list of those medications in my coat pocket (short coat of course), and discussed with my patients about changing some of the medications that they were having problems affording to comparable ones that they would be willing to pay only $4 for. Turns out, I changed some medications for quite a few of my patients on the wards, with the hopes that with the decreased cost, they'd have better compliance rates, and hopefully keep them out of the hospital for longer periods of time. Interestingly, this can be something that can easily be studied- determine compliance in a survey prior to the changes in medicines, measure objective parameters of overall health, determine reasons for admission to the hospital, then on follow up after discharge, see how the objective parameters improve and do a repeat survey to see if compliance has improved. Also, you can determine if the time between admissions increases most likely due to improved compliance especially for our "chronic admissions" that we all see at most hospitals.

In short, I would like to say Kudos to both Target and Wal-Mart for such a great plan. I hope that this may help our patients (from all income levels) improve their compliance due to overall decreased costs. That being said, MDs have to also do their part in reviewing a patient's medications, and determining if changing the medications to a less expensive alternative is a feasible option.

I suppose after I move to Boston, I will see whether or not the patients over there (where I assume many DO have insurance) have similar comliance issues because of cost. Does anyone else have any opinions on these plans? Do any of you take advantage of the $4 plans?

And it Begins...

Hello all!

I just wanted use my first post to briefly introduce myself and explain the rationale behind why I've created this blog. I am currently a fourth year medical student- about to graduate and become a "real doctor" in just about a month. I'm fairly new to the blogging world, and I've tried before to have a blog that was more about me- and realized that writing about me wasn't as interesting as I had hoped. So instead, what I've decided to do is write about my transition from becoming a medical student to becoming a doctor and what changes that I have to go through. On top of that, I want to write about healthcare issues that I have seen everyday during my last few years in medical school, and issues that I will be faced with in the upcoming years as an intern, resident, and full fledged physician.

As for some background info on me- I have been fortunate enough to have experienced many different places during my 25 years on this planet. I've spent the first half of my life in different parts of NJ, the second half in a suburb of New Orleans, with a short stint in North Louisiana for medical school. I will be starting a residency in Boston this summer, with the hopes of experiencing a new and exciting way to learn and practice medicine which I may one day be able to bring back to Louisiana when I'm all done.

What I would like to do on here is recall and write about things that I've seen, both positive and negative, with the healthcare system that I've been exposed to as a medical student. During my residency, I will be able to compare my medical school experiences to those experiences I will have in Boston, and hopefully draw some conclusions as to how we can make improvements in the delivery of healthcare in Louisiana. Although I know this is constantly discussed on the news and such, as a person who will have the opportunity to experience such a big difference in location, I hope that I can add a different perspective to the mix.

Most people who know me will attest to the fact that I talk "too much". Although I don't quite agree (well, maybe a little), I think using the WWW as another medium for my thoughts may help to curb the excessive verbage from my mouth :)

Lastly, I'd really like to hear input from others who may read my blog (if any...) The perspectives from both medical, and non-medical people are important factors when trying to implement changes that affect people on both sides of the line.