ACADEMY PUBLIC POLICIES

Why I Do It

At one of the health seminars I hold, someone once asked me why I do what I do. “Why do you care so much about health, why are you so passionate about it?”

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HOSPITALES

Healthcare System Overview

The Coming Health Care Tsunami

I heard a story told by a ten-year-old British girl, Tilly Smith, shortly after she had witnessed the Indonesian tsunami in December 2004. Tilly was on vacation at the beach in Phuket, Thailand, with herfamily. She suddenly saw everyone staring at the tide, which was rushing out. They looked on in amazement because the water was quickly receding, rather than rolling in as it normally does. But this little girl had studied giant waves, called tsunamis, just two weeks before in her geography class and quickly realized they were in danger. She told her mother that they had to leave the beach immediately-which her mother passed on to the other people on the beach and at the hotel, more than a hundred people. Everyone quickly evacuated before the wave struck the beach minutes later. No one at the beach was seriously injured or killed.

I feel a little bit like Tilly. We’re all standing at the beach-doctors, patients, the government, hospitals, drug companies, insurance companies, every one of us-looking at the water going out to sea, wondering, “Hmm? Why is it doing that?” That tide is our health care system. The water is rushing out to sea because a giant wave is building-a wave that’s going to come crashing down on all of us, causing enormous amounts of harm. I’m not screaming “Run!” but I will tell you that if you don’t get prepared, don’t become more aware of your health and how to get the health care you need, that wave is going to come crashing over you and the people you love. Let’s take a look at a few figures that indicate some frightening trends in our health care system.

• Dire shortage of family physicians predicted The American Academy of Family Physicians is predicting a dire shortage of family physicians in at least five states and serious shortages in other states by the year 2020. The number of Americans needing more health care (because of aging and chronic conditions) is skyrocketing. The organization says that we’ll need 40 percent more family doctors over the next fourteen years just to keep up with the demand. What’s so disturbing is that not only are we not getting more doctors, the number of U.S. medical graduates going into family practice has fallen by over 50 percent from 1997 to 2005, as more young doctors choose to pursue specialty practices that offer better hours, higher pay, and more prestige.

• Two-thirds of intensive care patients receive bad care The Health and Human Services Department reported findings in May 2006 that two out of three patients who need critical care aren’t getting proper care because of a serious shortage of critical care specialists (including doctors and nurses). This shortage results in the unnecessary deaths of up to 54,000 people every year.

• Emergency care crisis The Institutes of Medicine (a division of the National Academy of Sciences) issued a report in June 2006 on the frightening state of emergency medicine in the United States.

On top of a critical shortage of emergency room and ICU doctors, emergency rooms are overcrowded, causing ambulances to be sent to other hospitals, delaying care. It’s become common for emergency rooms to leave patients lying on gurneys or hospital beds parked in hallways (called boarding) for hours while they wait for someone to help them.

• 1.8 million people each year pick up infections in the hospital. These infections directly cause the death of 20,000 people each year and contribute to the death of 70,000 more. “But people have always gotten sick in the hospital-there’s just more germs there,” you might argue. But the rate of these infections has actually gone up 36 percent in the last twenty years, even as we’ve improved sterilization and developed drugs that fight infections. Health officials attribute this disturbing and deadly rise in infections to lax patient-safety practices in hospitals as well as the rise of antibiotic resistant bacteria strains in response to an overuse of antibiotics.

• One out of every five hundred people admitted to the hospital is killed by a mistake Compare that to the chance of being killed in a commercial airline accident, which is one per eight million flights.

• 35 to 40 percent of missed diagnoses result in death Prevention and early diagnosis isn’t just a perk. It’s what our system is supposed to be doing, yet it seems it’s failing at an alarming rate.

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Clean Sweep

Hospitals bring janitors to the front lines of infection control. When hospitals want to make a name for themselves, they spend on reputations and technology—on the esteemed surgeon or the top-of-the-line gamma knife and the star radiologist to operate it. Such investments attract publicity as well as patients seeking the best available health care. Lately, though, some hospitals have been making an unexpected discovery. The kinds of expenditures that truly improve patient care are often not directed at the top of their pay scale, with the famous specialists, but rather at the bottom, with the anonymous janitors.

Hospitals have reached this realization while trying to cope with an alarming trend. Over the past decade the organisms that cause most infections in hospitalized patients have become more difficult to treat. One reason is increasing drug resistance; some infections now respond to only one or two drugs in the vast armamentarium of antibiotics. But the problem also arises because the cast of organisms has changed.

Just a few years ago the poster bug for nasty bacteria that attack patients in hospitals was MRSA, or methicillin-resistant Staphylococcus aureus. Because MRSA clings to the skin, the chief strategy for limiting its spread was thorough hand washing. Now, however, the most dangerous bacteria are the ones that survive on inorganic surfaces such as keyboards, bed rails and privacy curtains. To get rid of these germs, hospitals must rely on the staff members who know every nook and cranny in each room, as well as which cleaning products contain which chemical compounds.

“Hand hygiene is very, very important,” says Michael Phillips, a hospital epidemiologist at New York University Langone Medical Center who has been studying this problem. “But we are coming to understand that it is one of just several important interventions necessary to break the chain of infection that threatens our patients.”

PERSISTENT PESTS

the infectious organisms that require all this extra effort became a serious problem around 10 years ago. The first outbreaks were caused by vancomycin-resistant Enterococcus, or VRE, and Clostridium difficile, known as C. diff, followed by a group of bacteria collectively referred to as highly resistant gram-negative organisms: Escherichia coli, Klebsiella, Pseudomonas and Acinetobacter.

This varied lot enters hospital rooms via multiple avenues. Acinetobacter and Pseudomonas prefer to live in the soil andwater, but they are carried into hospitals from the outside world on people’s shoes and clothes. In contrast, VRE, E. coli, Klebsiella and C. diff thrive inside human beings. These bacteria enter hospitals in patients’ intestines and escape when bedbound patients suffer from diarrhea, contaminating the air and equipment around them.

The new scourges are particularly tough to clear away for several reasons. The gram negatives, for instance, have a double wall that gives them extra defenses against antibiotics and shields them from damage by other compounds, including cleaning chemicals. Many of the bugs can survive in low-nutrient environments, such as glass, plastic, metal and other materials that make up a hospital room. Consider VRE. One strain that caused an outbreak at the University Medical Center Utrecht in the Netherlands grew in a lab dish for 1,400 days after being dried in a test that mimicked what might happen in a patient’s room. (MRSA also survives on surfaces, but for much shorter duration.) Because of such abilities, the latest bacterial threats create an infection risk at least as great as health care workers’ contaminated hands. “It forces us to raise the cleanliness of the hospital as a clinical issue, just as washing our hands is a clinical issue,” says Cliff McDonald, a medical epidemiologist at the U.S. Centers for Disease Control and Prevention.

Within hospitals, these resistant, hardy organisms are ubiquitous. A review article last year found that 10 percent of hard and soft surfaces in hospital rooms may be contaminated with gram-negative bacteria and that 15 percent of them may be contaminated with C. diff. A study at the University Of Iowa Carver College Of Medicine, published online in April, demonstrated the potential infection risk posed by the privacy curtains around hospital beds. In an initial survey, 95 percent of curtains in 30 rooms harbored VRE or MRSA. When the curtains were replaced, 92 percent became recontaminated within a week.

OPERATION CLEAN TEAM

Recently Hospital Cleanliness has become a matter of reputation, especially since the federal government’s Hospital Compare Web site started posting institutions’ rates of health care–associated infections. Cleanliness is also becoming a bottom-line issue: in 2008 the federal Centers for Medicare and Medicaid Services ceased reimbursing hospitals for the treatment of any infections that those hospitals caused-a controversial carrot and-stick venture that, according to new research, has successfully begun to lower infection rates.

Institutions also employ infection-control specialists, who track infections and investigate their causes. Yet when the problem is bacteria on surfaces, eliminating them depends on the building-services crews. “This is the level in the hospital hierarchy where you have the least investment, the least status and the least respect,” says Jan Patterson, president of the Society for Healthcare Epidemiology of America. Traditionally, medical centers regard janitors as disposable workers-hard to train because their first language may not be English and not worth training because they may not stay long in their jobs.

At N.Y.U. Langone in 2010, Phillips and his co-workers launched a pilot project that redefined those formerly disposable workers as critical partners in patient protection. Janitors, they realized, know better than anyone else which rails are touched most frequently and which handles are hardest to clean. The Langone “clean team” paired janitors with infectioncontrol specialists and nurses in five acute care units to ensure that all high-touch surfaces were thoroughly sanitized. In its first six months the project scored so high on key measures-reducing the occurrence of C. diff infections and the consumption of last-resort antibiotics-that the hospital’s administration agreed to make the experiment routine procedure throughout the facility. It now employs enough clean teams to assign them to every acute care bed in the hospital.

SHIELDED SURFACES

Even the most aggressive disinfecting regimen might miss something, though. Thus, some researchers are tackling a once unheard of goal: rooms that clean themselves. Most of their early work focuses on engineered coatings and textiles that rebuff infectious organisms or kill them.

A company called Sharklet Technologies imprints the surface of catheters with a pattern that mimics the scaly texture of sharkskin, an innovation inspired by the realization that sharks, unlike whales, do not develop encrustations of algae. In the company’s peer-reviewed research, the engineered surface makes it difficult for bacteria to cling and multiply. Other projects capitalize on the long-recognized antiseptic properties of precious metals, chiefly silver and copper. Metal ions seem to interfere with crucial proteins within bacterial cells. Those results are similar to the effect of some antibiotics, but the metals, unlike drugs, do not provoke resistance. Research by the company EOS Surfaces shows that bacteria in patients’ rooms cannot survive on wall panels sheathed in copper, and a study funded by the Department of Defense at three hospitals, including Memorial Sloan-Kettering Cancer Center in New York City, demonstrated an association between copper-coated “high touch” surfaces in rooms-the call button, intravenous pole and bed rails, among others-and lower infection rates. PurThread Technologies is developing a proprietary alloy of copper and silver, which it melts into polyester and spins into yarn that is eventually woven into textiles ranging from sheets to scrubs.

Infection-prevention specialists think these efforts are promising but still preliminary. Most have not been tested in randomized clinical trials that could record whether the engineered surfaces were solely responsible for reducing patient infections. “They need a lot more work, but I do think they will be a part of the solution,” says Eli Perencevich, an infection-control specialist at the University of Iowa and interim director of the Center for Comprehensive Access and Delivery Research and Evaluation at the Department of Veterans Affairs, who consults for PurThread. Yet, he adds, they will be one additional weapon against infections, not a replacement for other strategies: “We can never let go of making sure that surfaces are cleaned and that health care workers wear gloves and wash their hands.”

HEALTH POLICY - WHO

European Observatory on Health Systems and Policies

OECD Health Policy Studies

Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people.

So Who Put You in Charge

You’ll notice that the heading for this text isn’t phrased as a question, “Who Put You in Charge? ” but rather as a statement. That’s because there’s no question about it: you are in charge. If you doubt that for a minute, let me tell you one person’s story: I was on a weekend cruise, relaxing for once, sitting on the deck in the sun working at my computer (okay, only relaxing a little, but I was in the sun at least). A woman approached and asked if she could sit at my table and share my sunlight. “Please,” I said, offering her a chair.

“You’re just like my husband,” she laughed, nodding her head to indicate her husband sitting at another table in the shade a few yards away, “always working. I can’t believe you’re here, looking at this beautiful ocean, and neither of you can shut off your computers and just relax.” Sensing she wanted to talk, I closed the lid of my laptop and snuggled into my chair for a nice chat. What I didn’t expect was that I would still be working the way I usually do-listening to people’s health stories.

“I’m trying to get my husband to slow down because he’s been very sick.” “What has he been dealing with?” I asked. “Pancreatic cancer. Very advanced, usually deadly. But he’s out of the woods now, thank God. We had a tough battle, but it looks like he won.”

Listening to the background of his condition and treatment, I became fascinated when she spoke about how they had gone about getting treatment. “We just decided to fight the fight of our lives. We weren’t going to lie down and just watch him die. We used the Internet and books and friends and doctors to find out everything we could about the condition and what treatments were being used. We took charge of his condition [her words, not mine]. We found that there were only two doctors in the country that were doing the cutting edge surgery that we thought he needed, so we refinanced our house and picked up and went to Texas to get the treatment. And we never gave up. We had bad days-lots of them. But we saw this as a battle for which the only acceptable outcome was victory and I've just convinced that those two things-positive attitude and taking charge of our own care-are why my husband is sitting here today.”

“That’s amazing,” I said. And I meant it. What a wonderful, uplifting story. I could just see the love that woman had for her husband and the appreciation she had for the gift of having him with her today. But I couldn’t stop myself from thinking, “Why did it have to be that way? What about the people who didn’t know they had to take matters into their own hands, seek out the right doctors, find the newest treatment; that gave up on themselves and died without having a fighting chance? Wasn’t our system supposed to take care of them, too?”

As if reading my mind, the woman went on, “I know this is true because you’ll never believe it. One year after my husband was diagnosed, our minister found out he had the very same type of cancer. We talked to him about it, about what we had found out, how we’d fought for our lives, but he just didn’t want to hear it. You could see he had just given up. Six months later he died.” “I’m so sorry to hear that. That’s a tragedy,” I said. “I still wish I could get my husband off that darned computer,” she smiled.

The answer to who put you in charge is our health care system. Don’t doubt for a minute the first of Taylor’s Laws of Health that you’ll see throughout this book: you are on your own. You are on your own to make sure you don’t suddenly get a life threatening condition. You are on your own to make sure you don’t have a bad reaction to a medication. You are on your own to keep yourself safe when you are in the hospital. And you are certainly on your own when you need the care that will save your life. But saying you’re in charge and actually taking charge are two different things.

For some reason, when we enter the doctor’s exam room, years of maturity, responsibility, and knowledge just get washed away and there we are, in that little paper gown, sitting on that cold exam table, feeling about eight years old. Not just physically naked, but emotionally naked as well. Afraid to say what we want. Intimidated that we just don’t understand our own bodies. Embarrassed to talk about symptoms or admit to habits that are less than perfect. Our system was designed that way-to make us obedient patients who would listen to our doctors-but now that system has been turned on its head, putting your health, and your life, at risk.

The System Is Killing Us

Not only does the system do little to keep us from getting sick, in many instances it actually causes more problems than it fixes! Medical mistakes are a serious threat to your health and well-being. The total number of people who die every year from medical errors varies so widely and goes so unreported that I can’t really state an exact figure here. Take a look at some conservative estimates on medical mistakes:

Mistake Estimated Deaths Every Year

Adverse drug reactions 106,000

Medical errors 98,000

Bedsores and infections 203,000

Unnecessary procedures 37,000

Add to this an estimate of 8.9 million unnecessary hospitalisations every year and it’s enough to scare you into being healthy! In 1994, Dr Lucien Leape published a paper in the Journal of American Medicine titled “Error in Medicine” that took a good, hard look at the harm our system was doing to our health. Dr Leape compared the deaths from medical mistakes to the equivalent of three jumbo jets crashing every two days. At that error rate, I don’t think any of us would ever get on a plane again. Leape also acknowledged that because the data on medical errors are sparse and since we know that the vast majority goes unreported, his figures were probably very conservative. In fact, what Leape was saying is that a lot more people were dying than even his statistics, as troubling as they were, showed. Leape hoped this report would “fundamentally change the way [the medical community thinks] about errors and why they occur.” Sadly, over a decade later, no real changes have been made in our system, and people just keep dying. In fact, another report issued by the Institute of Medicine offered an even worse picture. In one part of their study, 1,047 patients admitted to a large teaching hospital were studied. Of those patients, 480, or 46 percent, had an adverse event- a situation where a bad decision was made. For 185 of those patients, the adverse event was serious, causing disability or death. Do the math on the number of patients in every hospital in the United States and the figure is astounding. How could it be that a system that’s supposed to save our lives instead kills more people each year than all other accidents combined? Are those hospitals literally more dangerous than war zones? To understand why these mistakes continue to happen, you have to understand how our medical system works.

Nobody’s Perfect, Right?

Our medical system operates on an infallibility model. It’s assumed that the doctors, nurses, technicians, and other people who provide your care will never make a mistake—will be infallible. “What’s so wrong with that?” you might ask. Well, for starters, you and I both know (and the system seems to demonstrate) that none of us is infallible. We all make mistakes. But having a system where perfection is presumed means that each person down the line assumes that what the person before them did was correct and so does nothing to double-check, take any steps to catch an error, or correct any errors that could have occurred, because, according to the system, no errors ever occur. This means that often errors get worse and worse and worse as they are compounded all down the line, eventually, in the worst cases, resulting in a patient’s death.

Even worse, there is such a stigma against reporting errors that almost all mistakes are swept under the carpet. This means they’re never examined to see how they could be prevented from happening again. It’s estimated that only 1.5 percent of all mistakes are ever reported, mostly by patients themselves! Doctors and nurses, living in fear of malpractice suits and disciplinary actions, have no training and no motivation to prevent and fix mistakes.

Doctors are suffering at the hands of our system as well. More and more medical students are being forced to turn away from what they love-treating patients-and turn to more lucrative specialities like plastic surgery, dermatology, and eye surgery.

A doctor whose daughter was in the same kindergarten class as my daughter told me of his struggle. I’m a family practice doctor-it’s what I like to do-but I’m going to have to give it up. I feel like I’ve tried everything but nothing’s working. First I took a job with a big medical practice as one of their staff physicians. But I was just asked to grind out as many appointments a day as possible-get ’em in, get ’em out, I used to say-and it just didn’t feel like I could give people the care I wanted to. So I decided to open my own practice.

I could see from the medical group that there sure wasn’t a lack of patients. But soon after I got started, I could see there was going to be a problem. I signed on with some health insurance plans and even some government plans. I agreed to take Medicare patients because I have a lot of experience with senior care. I started seeing patients and at first, it was great. I took my time, went over their history, ordered tests and screenings.

Then I started filing my claims. Oh my gosh. I admit it, the business side of being a doctor has never been my thing. I mean, I can do it, but I like concentrating on the patients. But anyway, the reimbursement rates were so low that I couldn’t even pay my office rent every month. One government plan paid me ten dollars for an office visit. These office visits were taking me around thirty minutes each. So I started doing what I was doing before, trying to move patients in and out as quickly as possible. But that’s just frustrating to both them and me. I know I need to be efficient, but I just don’t think I can give people the care I think they need under these circumstances. I’m going to start making mistakes and missing things and I just don’t want to practice like that.

That’s why it’s so important for you to be on top of your health and take charge of your care every step of the way. You are your own best advocate, and many times you are your only advocate. Even the most dedicated, talented doctors make mistakes and feel the push to move faster, do more. It’s your job, your responsibility; to do everything you can to help them do their job right to protect your life. But as you set out to take charge of your health, one of the challenges you face is how to sort through all of the information, the mixed messages, and the onslaught of marketing that is thrown at you about your health every single day.