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The Return of #JHMChat and Choosing Wisely

by Charlie M. Wray DO, MS
By: Charlie M. Wray DO, MS I’ll be honest – I can’t remember who won the 2012 Super Bowl, World Series or any other pop culture phenomenon*, but I do recall stumbling across something called Choosing Wisely® one afternoon while sitting in my clinic. With a burgeoning awareness that much of the care I was providing seemed superfluous and wasteful, the discovery that there was a group of physicians who shared this same sentiment was exciting! Five years in, the Choosing Wisely® campaign has published more than 500 specialty recommendations – with the Society of Hospital Medicine working on the upcoming version 2.0 (all are welcome to contribute!). Just as Choosing Wisely is gearing up for round 2, the Journal of Hospital Medicine’s (JHM) online journal club, #JHMChat, is rebooting as well! After a brief summer hiatus, we’re happy to announce that #JHMChat will be returning to discuss “Against Medical…
Charlie M. Wray DO, MS is an Assistant Professor of Medicine at the University of California, Francisco and the San Francisco VA Medical Center. He completed medical school at Western University – College of Osteopathic Medicine, residency at Loma Linda University Medical Center, and a Hospital Medicine Research Fellowship at The University of Chicago. Dr. Wray’s research interests are focused on inpatient care transitions, care fragmentation in the hospital setting, and overutilization of hospital resources. Additionally, he has strong interests in medical education, with specific focus in evidence-based medicine, the implementation of value-based care, and how learners negotiate medical uncertainty. Dr. Wray can often be found tweeting under @WrayCharles.

Should We Really Focus on “Patient-Centered” Care?

“Patient-centered care implies that the patient is always right and that their opinion should win out over the physician’s opinion.” I read that quote from Dr. Katie Neuendorf in a recent article in The Hospitalist, and it resonated with me right away. In the article, Dr. Neuendorf explains that patient-centered care should really be “relationship-centered care,” which means that the relationship should be prioritized, even when there is disagreement in the plan of care. In this scenario, she pointed out that she can support the patient and still not prescribe a treatment that she feels is inappropriate. This is brilliant and beautiful. We know, as numerous articles have shown us, that giving patients what they want is not necessarily good for them. Patients with the highest satisfaction scores also have the highest mortality ratings. This is thought to be because patients may be asking for interventions, tests or prescription drugs…

95% of Inpatient Providers Would Get an F On This Exam

You all think you know hospice. You don't, and I will tell you why. Hospice is a bastard child of the Medicare system. It went live in 1983 as a standalone entity during the Reagan administration and remains a disjointed program today. I would characterize its evolution as such: the road to hell is paved with good intentions. Why is that? When you go into hospice, your care path goes 180, and usual Medicare rules don't apply.  The benefit reroute sometimes makes life harder for families and patients.  It's like handing your keys off into the hospice kingdom--they run the show, and it's both a blessing and a curse. (more…)

Is It Time for Health Policy M&Ms?

[caption id="attachment_16917" align="alignnone" width="609"] https://twitter.com/ChrisMoriates/status/890259986873450508[/caption] There are few experiences in my medical training that felt more intimidating, and ultimately more impactful, than our Mortality and Morbidity (M&M) conferences. The patients whose diagnoses I missed. The times I should have called my attending or pushed harder for the cardiologist to come in overnight. They stick with me and I believe ultimately have helped make me a better doctor. This is why I was intrigued by the idea of explicitly incorporating health policy issues into M&M. Over the past few years, I increasingly have seen adverse events that result from issues related to health policy. Inability to access care for appropriate hospital follow-up. Failure to fill a critical prescription due to cost or gaps in coverage. A patient I admitted for “expedited work-up” for rectal bleeding after he told me he had been trying to get a recommended colonoscopy for many months…

You Have Lowered Length of Stay. Congratulations. You’re Fired.

For several decades, providers working within hospitals have had incentives to reduce stay durations and keep patient flow tip-top. DRG-based and capitated payments expedited that shift. Accompanying the change, physicians became more aware of the potential repercussions of sicker and quicker discharges. They began to monitor their care and as best as possible, use what measures they could ascertain as a proxy for quality (readmissions and hospital acquired conditions). Providers balanced the harms of a continued stay over the benefits of added days, not to mention the need for cost savings. However, the narrow focus on the hospital stay, the first three to seven days of illness, distracted us from the out weeks after discharge. With the acceleration of inpatient episodes, we cast patients to post-acute settings unprepared for the hardship they would face. By the latter, I mean, frailty risk, more reliance on others for help, and a greater need…
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