(also known as ‘Health Care Environmentalism’ or ‘Green Health Care’)

The two parts to this piece.

1. We waste a ton of material in health care. Can we reduce this safely?
2. We waste a ton of material to prevent and reduce infection; other industries must clean up their act because to some degree, we can’t.

Number One.
I don’t hear much about the topic, and while there’s a few organizations who are aware of it, we don’t discuss it much. It’s hard to imagine that hospitals create over 2 million tons of waste each year, but when you think how many nitrile gloves a person goes through in a typical day, it certainly adds up. Then add all the sharps (needles, syringes, guide wires, glass ampules, scalpels, instruments) and it adds up even more. Did you realize these kits just get thrown away? Metal tweezers and scissors, tossed away. Then add the gowns and kit packaging, and it gets even worse.

So first of all, can we do better? Can we reduce packaging, or identify recyclable materials? I would imagine some manufacturers are already looking into this as a way to reduce their costs, but certainly none of it is done around here, in the progressive stronghold of the Bay Area. (We certainly could save on paper by moving to electronic medical records as well.)

Number Two.
The reason there’s so much waste in the first place is to encourage sterility. When you typically open a package to do a procedure (a lumbar puncture, a central line, etc) you open up a water-resistant plastic kit with waxed-paper lid and find a paper-wrapped package inside, sterile on the inside. Often there’s also a gown inside to wear, as well as a standard size of sterile gloves to put on. You gown up, put on the sterile gloves, and now you can go through the insides of the package, which include: multiple needles, multiple syringes, guidewires, glass bottles with lidocaine in them, a disposalble scalpel, some suture with needle, and some skin-cleaning pads as well. All of this is packaged under sterile conditions, so that very limited bacteria will be present when you’re doing the procedure, to prevent the patient from getting an infection due to the procedure.

A lot of this we can’t easily eliminate without creating large hurdles to performing the procedure–and even if we packaged items separately, they would require separate sterile packaging, which may just add the trash mess as well, and taking more time to gather supplies. And the costs (financial as well as to the patient, obviously) to an infection in the blood are great–they can kill people. So a lot of this we can’t improve.

That’s why other industries need to do a better job of reducing their waste–because we in health care have some degree of “fixed” waste that we will always have (until we develop wireless IV tubing, of course). Other industries must work even harder to clean up their environmental acts to compensate for the continued mess that health care makes.

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(With apologies to the If You Give A Mouse A Cookie author)

If your Electronic Medical Record goes down (and your whole hospital is dependent upon it),
Then doctors can’t get labs and study results.
If doctors can’t get labs and study results,
Then doctors can’t write orders.
If doctors can’t write any orders,
Then nurses can’t do any orders.
If nurses can’t do any orders,
Then patients won’t get any better.
If patients don’t get any better,
Then patients can’t be discharged.
If patients can’t be discharged,
Then the hospital fills up with patients.
If the hospital fills up with patients,
Then there’s no place to put new patients or patients who get sicker.
If there’s no place to put new, sicker patients,
Then patients get worse, and you lose the whole point of having the hospital in the first place.

Here’s to good contingency plans, ’cause we all pretty much froze, opossum-in-the-headlights-style, today. How do we write orders? How do we write notes? How do we call consults? How do consults read prior notes and information?

IT people that work at a hospital: yes, your department now truly influences whether patients get better or worse, and indirectly, live or die.

(We had a ‘read-only’ version, which functioned reasonably well, but was far from optimal, to be sure.)

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The author of Nickel and Dimed discusses health care as she sees it.

I once tried to explain to a Norwegian woman why it was so hard for me to find health insurance. I’d had breast cancer, I told her, and she looked at me blankly. “But then you really need insurance, right?” Of course, and that’s why I couldn’t have it.

This is not because health insurance executives are meaner than other people, although I do not rule that out. It’s just that they’re running a business, the purpose of which is not to make people healthy, but to make money, and they do very well at that.

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Dr. Rangel’s piece, Lowered Expectations, makes a lot of hops, skips, and jumps of logic that I’m scratching my head at, as well as illustrates the issues that many physicians face in understanding and appreciating the health illiteracy of many of our patients. (Plug for my recent Op-Ed on health literacy!)

He starts out being upset with Medicare/Medicaid for requiring letters about denials for procedures or tests to be written at a 5th grade level–but I’d argue that’s not really too far off or inappropriate. A 1993 study (I know, almost 15 years old) showed 21-23% of adults functionally illiterate, and another 25-28% only marginally literate (equivalent to reading at or below a 5th grade reading level). I’d imagine this is why CMS uses the 5th grade standard–about half of the adult population cannot easily understand language beyond this (scary!). Adults with low literacy are also more likely to be poor as well (43% in poverty vs 4% in povery at the highest levels of literacy). See Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Department of Education;1993

Add on to this fact that health literacy is one step more complex than just reading basic information (you have to understand basic things about the body and drugs) and this can add to confusion. We also know that the elderly, immigrants, and the poor are more likely to have poor health literacy, and since those groups are often the people that Medicare and Medicaid serve, I don’t think this requirement is all that outlandish. (In fact, immigrants are more likely to be on Medicaid than their non-immigrant American counterparts.)

If we’re writing things or saying things to our patients that they don’t understand, what good is it to them or to us? How many times does Dr. Rangel–or myself, or any physician for that matter–say something that is so obvious to us that we don’t even realize our patients don’t understand it? It doesn’t even have to be “medical-ese;” just last month I overheard a patient asking about his heart arteries, wondering if they were blocked, and someone answered, “It appears to us that your plaque is stable.” Now, if you don’t know that a “clog” or a “blockage” in your coronary arteries is thought to be due to an unstable cholesterol plaque that ruptures and causes a clot of platelets, you won’t really know how the doctor answered the question.

He then goes on to talk about Medicare Part D (which I’m in agreement with–the implementation was and continues to be incredibly confusing, mostly because it was lobbied to death and one Representative called it “The Ugliest Night I Have Ever Seen”).

Next is the ultimate link to how terrible the world will be and how quickly the sky will fall when “socialized universal health care” takes over. The 5th grade reading level requirement is clearly unfair, since I’m sure he explains sensitivity, specificity, and positive and negative predictive value to all his asymptomatic patients who ask for whole body CT scans. And he’s never seen a patient who doesn’t know what his or her medications are for, or call their hydrochlorothiazide (a diuretic used mainly for blood pressure) a “water pill?” Or just refer to their pills as “the blue one,” or “the red one?” I’m all for encouraging and begging patients to take initiative and learn about the drugs they’re on and the diseases that they have, but you’ve got to meet them where they’re at. If they think they’re taking their diabetes drugs for “high sugars,” does it make sense to go way over their head with the pathophysiology of diabetes and insulin resistance?

I understand where he’s coming from–I really do–but I think it’s more a function of physicians being so entrenched in the medical world that we have no idea what it’s like to not understand medicine or drugs or disease. I think it’s actually almost impossible for us to truly understand the patient’s perspective sometimes, given all our background knowledge that we use and possess without even realizing it. Is it often overly simplified, especially at a 5th grade level? Sure, and this can cause problems, too. I guess I’d rather have all my patients have a basic understanding than some of them have no understanding at all.

He then jumps to this final conclusion, which I’m still trying to figure out:

If you think that you have it bad now with your private insurance company, just wait until the Federal government takes over and must severely limit health care consumption in order to be able to pay for the care of over 300 million Americans. At least your insurance company doesn’t automatically assume that you are 10 years old.

Quick bullet points, because there’s just a lack of understanding of health policy going on here:

• The federal government already pays for about 60% of health care costs.
• Under most “socialized universal health care” plans, money currently spent for private plans would be diverted to a centralized payer (ooh, scary!). All the money in the system would still be in the health care system.
• You’d also gain tens of billions of dollars by simplifying administrative overhead and waste ($80 billion toward patient care would go a long way).
• Economic predictions generally show an increase in health care expenditures over the first few years of a universal coverage plan, as folks that are uninsured or under-insured try to go get their health optimized, but this would then settle soon after.

I’d like to hear where your data for the “severely limited” health care consumption is, Dr. Rangel. I’m just not seeing it. Changes? Yes. Problems with the transition? Of course. Severe limitations? I’m just not buying it.

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Interesting study in the NEJM this week comparing patients with insurance before they turned 65 (and qualified for Medicare) versus those without insurance before they turned 65. The study found that those that were previously uninsured had higher medical costs from 65 on. Initially you may think this may be a “duh” factor–those who get health insurance will use more services than when they weren’t insured–but the factor persists for years. Since they weren’t insured, they probably weren’t getting the right medications (or any) for years, leading to more severe disease, making them sicker and costing more once they qualified for insurance.

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A lot of people are linking to this Huffington Post piece detailing the candidates’ health plans, but I’ll one-up y’all and link to Health 08, a great Kaiser Family Foundation site that looks at the candidates’ health plans in depth as well. It’s great!

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From the surgeon-blogger:

Let me say it up front: I favor some form of a single-payer system.* It’s my view that the many problems with such a system can be overcome: it’s not single payer per se, as I see it, to which people seem to object. It’s some of the accouterments. Before getting to that, I’ll state what I think is the obvious: having countless health insurance companies — many of them for-profit — sucks gazillions of dollars out of the health care realm, in form of profits to shareholders, salaries of executives, and tens of thousands of workers in cubicles. Both in the bowels of the insurers’ buildings, and in hospitals and clinics and medical offices around the country, people input data, make calls, argue for and against payments, follow differing contractual rules within and between companies; in short, money that could be spent on care of the sick is diverted into pockets of those who provide no actual service to those in need of it.

The biggest problems with Medicare are that it treats providers like shit, has stupid rules, and responds little, if at all, to input from those who know what’s going on. It not only doesn’t recognize, but actually deincentivizes excellence. No small things; but there’s no reason a single payer has to be that way. What I’m saying, basically, is this: let’s have a single payer, and let’s make it smart and responsive. I think it’s not categorically impossible.

I know I’m basically quoting his entire post, but he gives a good, fair perspective and raises his concerns with Medicare and single-payer without saying it’s hopeless, and admitting that having such administrative duplication has to waste huge amounts of money that could be going toward patient care.

(Just one critique, Dr. Schwab–Canada is single-payer: doctors are private, clinics are privately owned, and hospitals aren’t run by the government. They’re just paid for by the government.)

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Waiting lists can be a form of rationing, but it’s far more humane than denial of treatment through systematic exclusion from most of the health system (which is what lack of coverage means). Great post.

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Of course, my Op-Ed opinion piece for the local NPR station got trumped by another piece on the exact same topic, Health Literacy. Never mind them, I’ll just publish it myself. Enjoy. (Click on the play button to… play.) Or just read along.

I visited an elementary school last week to answer some students’ health questions, and it was fantastic. I was thrilled to see them engaged and learning about their health and bodies–because I have a number of patients who know nothing about their diseases or medications.

Being a medical student gives me a magic power: the ability to instantly recognize my patients’ eyes glazing over, confused or unsure about what a doctor is saying. Doctors these days are under immense time pressure, and often don’t even realize when patients are lost. I’m something of a quasi-doctor: I understand the basics of diagnosis and treatment from the medical side, but I’m still able to take a patient’s perspective and realize when something may be over his or her head.

Part of this poor communication comes from “doctor-talk,” the language that we speak to each other, with such wonderful terms as “diaphoretic” (that just means “sweaty”). (Part of my job as a medical student is to learn the doctor-talk so I can communicate accurately and effectively. It’s *not* to make patients feel stupid or small, although I know it often has that effect.)

Sometimes we forget to switch back into English for our patients. Other times patient confusion is due to cultural factors, poor translation, or a lack of understanding about the body or disease. And even if doctors *do* try to make sure patients understand, guilt or embarrassment make some patients nod their heads anyway.

A major component of this confusion is “health literacy.” People who are not health literate have problems understanding pill bottle instructions or side effects, or even realizing why diseases like diabetes or hypertension are important to control. There are almost 90 million adults in the US who have only limited health literacy skills–that’s more than 4 in 10.

We often see the consequences of health illiteracy in the ER–my future specialty. I may diagnose a patient with a kidney infection, only to find out antibiotics were already prescribed by another ER, but the patient simply isn’t taking them. The communication of “You must take these to get better” got lost somewhere along the line, for any number of reasons. An extra 30 seconds of explanation can often save a patient a lot of pain, an ER visit… and many health care dollars.

We often refer to “futile care” as the exhorbitant costs of sustaining a dying patient, but we clearly deliver “futile care” to young, healthy patients all the time, too–it’s effort just as wasted if the patient doesn’t understand what he or she needs to do to get better (or not get worse). Why diagnose and treat patients if they don’t understand the treatment plan? A magic cancer pill is useless if the patient doesn’t understand how, when, and why to take it correctly. As physicians, we must do better.

But we need your help as patients, too, because we’re in a time-crunched world with lots of sick patients with many problems. Here’s what you can do:

1) Ask questions if you don’t understand something.
2) Write your questions down so they’re efficient to answer.

These are simple solutions, and will help us all in the long run.

In fact, I propose a new health care button for doctors’ white coats, right next to the “Ask me if I’ve washed my hands” one. How about: “Ask me… what the heck I’m saying.”

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I would think that a policy wonk for a conservative think tank would be above taking cheap shots at a tragedy, especially when said tragedy is anecdotal and proves nothing, but I guess not. David Hogberg somehow equates the latest controversy at Drew/Harbor hopsital with that scary world of socialized medicine, so I’m happy to fire back with anecdotes myself.

One hospital in California did unnecessary heart surgeries.

Another hospital was fined more than $700 MILLION for defrauding Medicare (and by relation, US taxpayers.

One private psychiatric hospital locked up patients and held them against their will until their insurance ran out. (No, I’m not making that one up.)

Where did this happen? Canada, the UK, Japan? No, it’s right here in the US. The first was a hospital owned by Tenet, the second HCA, the largest private hospital chain the country, and the third was National Medical Enterprises, now known as… Tenet.

And all three of these are privately owned hospital chains. That what you want from your health care system? One that puts profits over patient safety and proper treatment and diagnosis?

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