Teachable Moments

Although thromboembolism, including deep venous thrombosis and pulmonary embolism, is a common diagnosis, it is nonetheless a very discouraging one. While it may be unpleasant for us to treat patients who suffer a DVT or acute PE, we see only a portion of what they actually endure. After discharge, chances are we will never see them again.

I often think about how burdensome it will be for my patients to have to see a doctor regularly and have their warfarin (Coumadin) dose adjusted based on the current international normalized ratio (INR), which seems to fluctuate at the drop of a dime.

©jimdeli/Fotolia.com

Most of us have treated patients ranging from robust young men who suffered a PE after a simple arthroscopic knee procedure from a sports injury to sweet, elderly little ladies who have no meaningful transportation to and from the doctor’s office. We worry about how compliant they will be with their prescribed regimen.

When given the diagnosis and treatment, patients almost universally ask how long they will have to stay on warfarin, and many are visibly upset when given the not-so-good news that they should plan to take it for 6 months, maybe longer.

Complications of warfarin therapy are common: the hematocrit of 18 or the hard-to-control epistaxis. But since there is no Food and Drug Administration–approved alternative for managing thromboembolism for the necessary 6 months or so, we have no choice but to prescribe this drug, counsel patients on signs of occult bleeding, and hope for the best. When facing the potential for a fatal pulmonary embolism, the risk-benefit ratio is unquestionably in favor of taking this drug for the vast majority of patients.

But what about the recurrent episodes of DVT or PE after stopping anticoagulation? It is well known that the risk for recurrence persists for years after discontinuing warfarin, particularly in those who had an unprovoked venous thromboembolism. Well, for the first time in ages, there is very encouraging news we can give our patients.

An article published recently in the New England Journal of Medicine, Aspirin for Preventing the Recurrence of Venous Thromboembolism, sheds light on a very simple therapy that can make a huge impact (2012; 366:1959-67). The Aspirin for the Prevention of Recurrent Venous Thromboembolism study randomized patients who had suffered a first-ever, objectively confirmed, symptomatic unprovoked proximal DVT within 2 weeks of discontinuing vitamin K antagonist therapy. Aspirin 100 mg daily was compared with placebo for 2 years.

Researchers found that aspirin therapy, started after 6-18 months of oral anticoagulant therapy, decreased the rate of recurrent venous thromboembolism by 40% when compared with placebo, with no significant increase in the risk of major bleeding. Finally, good news for our patients with DVT/PE. Hooray!

While we will rarely be the ones discontinuing warfarin after 6 months, just letting our patients know that aspirin therapy can decrease the risk of future events can be very reassuring.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Although thromboembolism, including deep venous thrombosis and pulmonary embolism, is a common diagnosis, it is nonetheless a very discouraging one. While it may be unpleasant for us to treat patients who suffer a DVT or acute PE, we see only a portion of what they actually endure. After discharge, chances are we will never see them again.

I often think about how burdensome it will be for my patients to have to see a doctor regularly and have their warfarin (Coumadin) dose adjusted based on the current international normalized ratio (INR), which seems to fluctuate at the drop of a dime.

©jimdeli/Fotolia.com

Most of us have treated patients ranging from robust young men who suffered a PE after a simple arthroscopic knee procedure from a sports injury to sweet, elderly little ladies who have no meaningful transportation to and from the doctor’s office. We worry about how compliant they will be with their prescribed regimen.

When given the diagnosis and treatment, patients almost universally ask how long they will have to stay on warfarin, and many are visibly upset when given the not-so-good news that they should plan to take it for 6 months, maybe longer.

Complications of warfarin therapy are common: the hematocrit of 18 or the hard-to-control epistaxis. But since there is no Food and Drug Administration–approved alternative for managing thromboembolism for the necessary 6 months or so, we have no choice but to prescribe this drug, counsel patients on signs of occult bleeding, and hope for the best. When facing the potential for a fatal pulmonary embolism, the risk-benefit ratio is unquestionably in favor of taking this drug for the vast majority of patients.

But what about the recurrent episodes of DVT or PE after stopping anticoagulation? It is well known that the risk for recurrence persists for years after discontinuing warfarin, particularly in those who had an unprovoked venous thromboembolism. Well, for the first time in ages, there is very encouraging news we can give our patients.

An article published recently in the New England Journal of Medicine, Aspirin for Preventing the Recurrence of Venous Thromboembolism, sheds light on a very simple therapy that can make a huge impact (2012; 366:1959-67). The Aspirin for the Prevention of Recurrent Venous Thromboembolism study randomized patients who had suffered a first-ever, objectively confirmed, symptomatic unprovoked proximal DVT within 2 weeks of discontinuing vitamin K antagonist therapy. Aspirin 100 mg daily was compared with placebo for 2 years.

Researchers found that aspirin therapy, started after 6-18 months of oral anticoagulant therapy, decreased the rate of recurrent venous thromboembolism by 40% when compared with placebo, with no significant increase in the risk of major bleeding. Finally, good news for our patients with DVT/PE. Hooray!

While we will rarely be the ones discontinuing warfarin after 6 months, just letting our patients know that aspirin therapy can decrease the risk of future events can be very reassuring.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Although thromboembolism, including deep venous thrombosis and pulmonary embolism, is a common diagnosis, it is nonetheless a very discouraging one. While it may be unpleasant for us to treat patients who suffer a DVT or acute PE, we see only a portion of what they actually endure. After discharge, chances are we will never see them again.

I often think about how burdensome it will be for my patients to have to see a doctor regularly and have their warfarin (Coumadin) dose adjusted based on the current international normalized ratio (INR), which seems to fluctuate at the drop of a dime.

©jimdeli/Fotolia.com

Most of us have treated patients ranging from robust young men who suffered a PE after a simple arthroscopic knee procedure from a sports injury to sweet, elderly little ladies who have no meaningful transportation to and from the doctor’s office. We worry about how compliant they will be with their prescribed regimen.

When given the diagnosis and treatment, patients almost universally ask how long they will have to stay on warfarin, and many are visibly upset when given the not-so-good news that they should plan to take it for 6 months, maybe longer.

Complications of warfarin therapy are common: the hematocrit of 18 or the hard-to-control epistaxis. But since there is no Food and Drug Administration–approved alternative for managing thromboembolism for the necessary 6 months or so, we have no choice but to prescribe this drug, counsel patients on signs of occult bleeding, and hope for the best. When facing the potential for a fatal pulmonary embolism, the risk-benefit ratio is unquestionably in favor of taking this drug for the vast majority of patients.

But what about the recurrent episodes of DVT or PE after stopping anticoagulation? It is well known that the risk for recurrence persists for years after discontinuing warfarin, particularly in those who had an unprovoked venous thromboembolism. Well, for the first time in ages, there is very encouraging news we can give our patients.

An article published recently in the New England Journal of Medicine, Aspirin for Preventing the Recurrence of Venous Thromboembolism, sheds light on a very simple therapy that can make a huge impact (2012; 366:1959-67). The Aspirin for the Prevention of Recurrent Venous Thromboembolism study randomized patients who had suffered a first-ever, objectively confirmed, symptomatic unprovoked proximal DVT within 2 weeks of discontinuing vitamin K antagonist therapy. Aspirin 100 mg daily was compared with placebo for 2 years.

Researchers found that aspirin therapy, started after 6-18 months of oral anticoagulant therapy, decreased the rate of recurrent venous thromboembolism by 40% when compared with placebo, with no significant increase in the risk of major bleeding. Finally, good news for our patients with DVT/PE. Hooray!

While we will rarely be the ones discontinuing warfarin after 6 months, just letting our patients know that aspirin therapy can decrease the risk of future events can be very reassuring.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Few things are scarier than the sudden loss of "life as we know it." At least with most devastating diseases there is time to come to grips with fate, but with a stroke, life may be completely normal one minute, and the next, one is thrust into an unknown world, from which there is potentially no return.

We know that patients can go from being independent and energetic to being partially paralyzed, confused, incontinent, and even completely dependent on others for even the most basic activities of daily living. Fortunately, in 2012, there are many success stories as well. While we are saddened about the former, we should focus most of our attention on preventing bad outcomes and optimizing the chances our patients will not have future cerebrovascular events.

Today, in part because of better public awareness of signs and symptoms, stroke and TIA are common reasons for admission to the hospital. I have had numerous patients express their embarrassment for going to the ER for their symptoms, and I always try to reassure them it is better to be safe than sorry. We can always discharge them home – healthy and happy – if we don’t find anything wrong.

Even if a patient has not suffered a stroke, but has a history strongly suspicious for a TIA, studies show that rapid intervention can significantly decrease their risk of having a stroke in the future, such as initiating antiplatelet therapy (unless contraindicated or anticoagulation is more appropriate) and statin therapy, counseling on lifestyle changes, controlling blood pressure, and in some cases referring for a carotid endarterectomy or stenting. An article in the New England Journal of Medicine titled "Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack," reviews some important information to have in mins (N. Engl. J. Med. 2012;366:1914-22). For instance, a randomized, controlled pilot trial demonstrated that the rate of stroke recurrence was 10.8% vs. 7.1% among those randomly assigned to aspirin within 24 hours of a stroke, compared to those assigned to aspirin and clopidogrel.

While prolonged exposure to both antiplatelet agents was shown to be linked to excess hemorrhages and deaths in the Secondary Prevention of Small Subcortical Strokes trial, it is proposed that short-term use of this combination may be beneficial since the risk of stroke is highest soon after a minor stroke or TIA.

Sometimes, we just have to weigh the risks and benefits. Many patients are hesitant to take blood thinners because they bruise easily or have other non-life-threatening side effects. But for most, when they understand the significant benefit of preventing a potentially disabling stroke versus the relatively minimal risk, they agree to comply, even if only temporarily.

Of course, aggressive risk-factor modification and lifestyle changes are in order for many patients who present with TIA and stroke as well, and what better audience can we ever hope to have than those patients who were just spared a catastrophic stroke. In the INTERSTROKE case-control study involving first-time acute strokes (Lancet 2010;376:112-23), researchers found that 10 risk factors accounted for 90% of stroke risk:

1. Hypertension

2. Current smoking

3. High waist-to-hip ratio

4. High dietary risk score

5. Lack of regular physical activity

6. Diabetes mellitus

7. Excess alcohol consumption

8. Psychosocial stress or depression

9. Cardiac causes

10. High ratio of apolioprotein B to apolipoprotein A1.

While we may not be able to affect change in all 10 risk factors, we can certainly make in a dent, if not affect a 180-degree turn around in most of them. Stroke and TIA patients are the ideal patient population to educate. They are uniquely motivated to make the changes needed to prevent a life-altering stroke.

Dr. Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Few things are scarier than the sudden loss of "life as we know it." At least with most devastating diseases there is time to come to grips with fate, but with a stroke, life may be completely normal one minute, and the next, one is thrust into an unknown world, from which there is potentially no return.

We know that patients can go from being independent and energetic to being partially paralyzed, confused, incontinent, and even completely dependent on others for even the most basic activities of daily living. Fortunately, in 2012, there are many success stories as well. While we are saddened about the former, we should focus most of our attention on preventing bad outcomes and optimizing the chances our patients will not have future cerebrovascular events.

Today, in part because of better public awareness of signs and symptoms, stroke and TIA are common reasons for admission to the hospital. I have had numerous patients express their embarrassment for going to the ER for their symptoms, and I always try to reassure them it is better to be safe than sorry. We can always discharge them home – healthy and happy – if we don’t find anything wrong.

Even if a patient has not suffered a stroke, but has a history strongly suspicious for a TIA, studies show that rapid intervention can significantly decrease their risk of having a stroke in the future, such as initiating antiplatelet therapy (unless contraindicated or anticoagulation is more appropriate) and statin therapy, counseling on lifestyle changes, controlling blood pressure, and in some cases referring for a carotid endarterectomy or stenting. An article in the New England Journal of Medicine titled "Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack," reviews some important information to have in mins (N. Engl. J. Med. 2012;366:1914-22). For instance, a randomized, controlled pilot trial demonstrated that the rate of stroke recurrence was 10.8% vs. 7.1% among those randomly assigned to aspirin within 24 hours of a stroke, compared to those assigned to aspirin and clopidogrel.

While prolonged exposure to both antiplatelet agents was shown to be linked to excess hemorrhages and deaths in the Secondary Prevention of Small Subcortical Strokes trial, it is proposed that short-term use of this combination may be beneficial since the risk of stroke is highest soon after a minor stroke or TIA.

Sometimes, we just have to weigh the risks and benefits. Many patients are hesitant to take blood thinners because they bruise easily or have other non-life-threatening side effects. But for most, when they understand the significant benefit of preventing a potentially disabling stroke versus the relatively minimal risk, they agree to comply, even if only temporarily.

Of course, aggressive risk-factor modification and lifestyle changes are in order for many patients who present with TIA and stroke as well, and what better audience can we ever hope to have than those patients who were just spared a catastrophic stroke. In the INTERSTROKE case-control study involving first-time acute strokes (Lancet 2010;376:112-23), researchers found that 10 risk factors accounted for 90% of stroke risk:

1. Hypertension

2. Current smoking

3. High waist-to-hip ratio

4. High dietary risk score

5. Lack of regular physical activity

6. Diabetes mellitus

7. Excess alcohol consumption

8. Psychosocial stress or depression

9. Cardiac causes

10. High ratio of apolioprotein B to apolipoprotein A1.

While we may not be able to affect change in all 10 risk factors, we can certainly make in a dent, if not affect a 180-degree turn around in most of them. Stroke and TIA patients are the ideal patient population to educate. They are uniquely motivated to make the changes needed to prevent a life-altering stroke.

Dr. Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Few things are scarier than the sudden loss of "life as we know it." At least with most devastating diseases there is time to come to grips with fate, but with a stroke, life may be completely normal one minute, and the next, one is thrust into an unknown world, from which there is potentially no return.

We know that patients can go from being independent and energetic to being partially paralyzed, confused, incontinent, and even completely dependent on others for even the most basic activities of daily living. Fortunately, in 2012, there are many success stories as well. While we are saddened about the former, we should focus most of our attention on preventing bad outcomes and optimizing the chances our patients will not have future cerebrovascular events.

Today, in part because of better public awareness of signs and symptoms, stroke and TIA are common reasons for admission to the hospital. I have had numerous patients express their embarrassment for going to the ER for their symptoms, and I always try to reassure them it is better to be safe than sorry. We can always discharge them home – healthy and happy – if we don’t find anything wrong.

Even if a patient has not suffered a stroke, but has a history strongly suspicious for a TIA, studies show that rapid intervention can significantly decrease their risk of having a stroke in the future, such as initiating antiplatelet therapy (unless contraindicated or anticoagulation is more appropriate) and statin therapy, counseling on lifestyle changes, controlling blood pressure, and in some cases referring for a carotid endarterectomy or stenting. An article in the New England Journal of Medicine titled "Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack," reviews some important information to have in mins (N. Engl. J. Med. 2012;366:1914-22). For instance, a randomized, controlled pilot trial demonstrated that the rate of stroke recurrence was 10.8% vs. 7.1% among those randomly assigned to aspirin within 24 hours of a stroke, compared to those assigned to aspirin and clopidogrel.

While prolonged exposure to both antiplatelet agents was shown to be linked to excess hemorrhages and deaths in the Secondary Prevention of Small Subcortical Strokes trial, it is proposed that short-term use of this combination may be beneficial since the risk of stroke is highest soon after a minor stroke or TIA.

Sometimes, we just have to weigh the risks and benefits. Many patients are hesitant to take blood thinners because they bruise easily or have other non-life-threatening side effects. But for most, when they understand the significant benefit of preventing a potentially disabling stroke versus the relatively minimal risk, they agree to comply, even if only temporarily.

Of course, aggressive risk-factor modification and lifestyle changes are in order for many patients who present with TIA and stroke as well, and what better audience can we ever hope to have than those patients who were just spared a catastrophic stroke. In the INTERSTROKE case-control study involving first-time acute strokes (Lancet 2010;376:112-23), researchers found that 10 risk factors accounted for 90% of stroke risk:

1. Hypertension

2. Current smoking

3. High waist-to-hip ratio

4. High dietary risk score

5. Lack of regular physical activity

6. Diabetes mellitus

7. Excess alcohol consumption

8. Psychosocial stress or depression

9. Cardiac causes

10. High ratio of apolioprotein B to apolipoprotein A1.

While we may not be able to affect change in all 10 risk factors, we can certainly make in a dent, if not affect a 180-degree turn around in most of them. Stroke and TIA patients are the ideal patient population to educate. They are uniquely motivated to make the changes needed to prevent a life-altering stroke.

Dr. Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Health care in America has changed radically over the past few decades, and will continue to re-create itself over and over again in the foreseeable future. When I was a little girl, I remember helping my father, a general practitioner, fill out his billing forms. My job was to record office calls by writing "OC $5" in a little slot about a third of way down the page, and by the time I reached high school, it had changed to "OC $7." Back in the 1970s, doctors seemed to be held in much higher regard than they are these days, and patients seemed to willingly accept a passive role in their own health care. It was almost as if they felt that questioning their doctor was simply outside of the realm of what reason and respect.

Today, patients are not only encouraged to ask questions, but their opinion of their doctors also will play a significant role in how much hospitals will be paid for services provided. While the U.S. Department of Health and Human Services has had a website where consumers can compare hospitals for more than 8 years, soon there will be yet another marker for how health care is delivered (and received) in America.

In October, more than 3,000 acute care hospitals will take part in Medicare’s new value-based purchasing program. Under this program, Medicare will reduce payments to hospitals by 1% and put that revenue aside for a bonus pool. In October 2016, that pool will double to 2% of Medicare payments.

Those hospitals that score above average on the measurements chosen or show the greatest improvement in performance during the previous year will receive money from this bonus pool. How much is in this pool? An estimated $850 million in the first year of the program alone.

While 70% of the initial bonuses will be paid based on 12 clinical care measures, the remaining 30% will be patient driven. Some of the proposed topics patients will be asked about include how doctors and nurses communicated with them, how well their pain was controlled, and how clean their rooms were.

"In many ways, it’s a watershed moment for the health care system," said Dr. Ashish Jha, a professor at the Harvard School of Public Health, Boston, who has studied hospital quality. "It’s a modest amount of money and not something that’s going to radically change the way we pay for hospital care in America. But it’s a really important step toward paying for better care and not just for more care."

A recent study lends credence to the hypothesis that patients’ perceptions of hospitals were often tied to the quality of care they received. In an article titled "Associations between Web-based patient ratings and objective measures of hospital quality," (Arch. Intern. Med. 2012;172:435-6) researchers compared hospitals with the best ratings on NHS Choices (a UK website) with those with the worst ratings and found that readmission rates were 11% lower in the higher-rated hospitals than in those with lower ratings, while mortality rates were 5% lower in the higher-rated hospitals. They also found that the hospitals with 25% best cleanliness ratings had a whopping 42% lower rate of MRSA infections than did those with the 25% worst cleanliness ratings.

The bottom line is that "good patient outcomes" are more far reaching than whether patients survived their hospital stay and returned to their prehospitalization state of physical health. Their mental and emotional well-being, as well as their perception of their environment and their overall experience while under our care, need to be a high priority, no matter how busy our days.

Encouraging patients to engage us and share their true fears, likes, and dislikes not only can help strengthen the doctor-patient bond, it can also lead to a better patient experience for the, and a better reputation for the hospitals we serve.

Dr. A. Maria Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Health care in America has changed radically over the past few decades, and will continue to re-create itself over and over again in the foreseeable future. When I was a little girl, I remember helping my father, a general practitioner, fill out his billing forms. My job was to record office calls by writing "OC $5" in a little slot about a third of way down the page, and by the time I reached high school, it had changed to "OC $7." Back in the 1970s, doctors seemed to be held in much higher regard than they are these days, and patients seemed to willingly accept a passive role in their own health care. It was almost as if they felt that questioning their doctor was simply outside of the realm of what reason and respect.

Today, patients are not only encouraged to ask questions, but their opinion of their doctors also will play a significant role in how much hospitals will be paid for services provided. While the U.S. Department of Health and Human Services has had a website where consumers can compare hospitals for more than 8 years, soon there will be yet another marker for how health care is delivered (and received) in America.

In October, more than 3,000 acute care hospitals will take part in Medicare’s new value-based purchasing program. Under this program, Medicare will reduce payments to hospitals by 1% and put that revenue aside for a bonus pool. In October 2016, that pool will double to 2% of Medicare payments.

Those hospitals that score above average on the measurements chosen or show the greatest improvement in performance during the previous year will receive money from this bonus pool. How much is in this pool? An estimated $850 million in the first year of the program alone.

While 70% of the initial bonuses will be paid based on 12 clinical care measures, the remaining 30% will be patient driven. Some of the proposed topics patients will be asked about include how doctors and nurses communicated with them, how well their pain was controlled, and how clean their rooms were.

"In many ways, it’s a watershed moment for the health care system," said Dr. Ashish Jha, a professor at the Harvard School of Public Health, Boston, who has studied hospital quality. "It’s a modest amount of money and not something that’s going to radically change the way we pay for hospital care in America. But it’s a really important step toward paying for better care and not just for more care."

A recent study lends credence to the hypothesis that patients’ perceptions of hospitals were often tied to the quality of care they received. In an article titled "Associations between Web-based patient ratings and objective measures of hospital quality," (Arch. Intern. Med. 2012;172:435-6) researchers compared hospitals with the best ratings on NHS Choices (a UK website) with those with the worst ratings and found that readmission rates were 11% lower in the higher-rated hospitals than in those with lower ratings, while mortality rates were 5% lower in the higher-rated hospitals. They also found that the hospitals with 25% best cleanliness ratings had a whopping 42% lower rate of MRSA infections than did those with the 25% worst cleanliness ratings.

The bottom line is that "good patient outcomes" are more far reaching than whether patients survived their hospital stay and returned to their prehospitalization state of physical health. Their mental and emotional well-being, as well as their perception of their environment and their overall experience while under our care, need to be a high priority, no matter how busy our days.

Encouraging patients to engage us and share their true fears, likes, and dislikes not only can help strengthen the doctor-patient bond, it can also lead to a better patient experience for the, and a better reputation for the hospitals we serve.

Dr. A. Maria Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Health care in America has changed radically over the past few decades, and will continue to re-create itself over and over again in the foreseeable future. When I was a little girl, I remember helping my father, a general practitioner, fill out his billing forms. My job was to record office calls by writing "OC $5" in a little slot about a third of way down the page, and by the time I reached high school, it had changed to "OC $7." Back in the 1970s, doctors seemed to be held in much higher regard than they are these days, and patients seemed to willingly accept a passive role in their own health care. It was almost as if they felt that questioning their doctor was simply outside of the realm of what reason and respect.

Today, patients are not only encouraged to ask questions, but their opinion of their doctors also will play a significant role in how much hospitals will be paid for services provided. While the U.S. Department of Health and Human Services has had a website where consumers can compare hospitals for more than 8 years, soon there will be yet another marker for how health care is delivered (and received) in America.

In October, more than 3,000 acute care hospitals will take part in Medicare’s new value-based purchasing program. Under this program, Medicare will reduce payments to hospitals by 1% and put that revenue aside for a bonus pool. In October 2016, that pool will double to 2% of Medicare payments.

Those hospitals that score above average on the measurements chosen or show the greatest improvement in performance during the previous year will receive money from this bonus pool. How much is in this pool? An estimated $850 million in the first year of the program alone.

While 70% of the initial bonuses will be paid based on 12 clinical care measures, the remaining 30% will be patient driven. Some of the proposed topics patients will be asked about include how doctors and nurses communicated with them, how well their pain was controlled, and how clean their rooms were.

"In many ways, it’s a watershed moment for the health care system," said Dr. Ashish Jha, a professor at the Harvard School of Public Health, Boston, who has studied hospital quality. "It’s a modest amount of money and not something that’s going to radically change the way we pay for hospital care in America. But it’s a really important step toward paying for better care and not just for more care."

A recent study lends credence to the hypothesis that patients’ perceptions of hospitals were often tied to the quality of care they received. In an article titled "Associations between Web-based patient ratings and objective measures of hospital quality," (Arch. Intern. Med. 2012;172:435-6) researchers compared hospitals with the best ratings on NHS Choices (a UK website) with those with the worst ratings and found that readmission rates were 11% lower in the higher-rated hospitals than in those with lower ratings, while mortality rates were 5% lower in the higher-rated hospitals. They also found that the hospitals with 25% best cleanliness ratings had a whopping 42% lower rate of MRSA infections than did those with the 25% worst cleanliness ratings.

The bottom line is that "good patient outcomes" are more far reaching than whether patients survived their hospital stay and returned to their prehospitalization state of physical health. Their mental and emotional well-being, as well as their perception of their environment and their overall experience while under our care, need to be a high priority, no matter how busy our days.

Encouraging patients to engage us and share their true fears, likes, and dislikes not only can help strengthen the doctor-patient bond, it can also lead to a better patient experience for the, and a better reputation for the hospitals we serve.

Dr. A. Maria Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.

What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?

These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.

A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.

However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.

Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?  

A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).

In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.  

While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.

What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?

These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.

A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.

However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.

Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?  

A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).

In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.  

While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.

What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?

These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.

A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.

However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.

Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?  

A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).

In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.  

While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

When I was in medical school, there was a very popular book called "The House of God." It dealt with the way doctors can sometimes elevate themselves to the level of a deity in their minds. But although physicians are highly trained professionals, we do not really have the final say in life. We have all pronounced dead rich patients, poor patients, happy patients, and sad patients. And one thing is for sure: No matter who we are, we all will meet the same fate one day. Frequently, patients are far more in tune to this reality than we are.

A Gallup poll, conducted in June of 2011, found that 92% of Americans believe in God. Among those with at least some college education, 93% believe in God; 94% of those who graduated college believe, and 87% of those with postgraduate training were found to believe in a deity.

©Amanda Rohde/iStockphoto.com

One thing that makes America great is that we each have the freedom to worship – or not worship – as we choose, and even among the majority of us who believe in God, there is a wide range of beliefs. Although many physicians may feel uncomfortable "mixing science and religion," I believe we do our patients a disservice when we refuse to acknowledge their feelings or pooh-pooh their beliefs.

We have all had patients whose prior doctors gave them 3-6 months to live – about 20-30 years ago, that is. And then there were those patients who had unwavering faith despite all odds, and even had family members and clergy come to pray with them, and did exceptionally well, despite our grim prognoses.

I suspect that there are several reasons physicians shy away from spirituality. One reason is that we are afraid that our words could be misconstrued as somehow unethical, and in certain situations, they may be. As in most things, prudence is in order. However, only the rare physician would use the vulnerability of sick patients to try to convert them to religion.

At the other end of the spectrum, we find many physicians who, when faced with a patient who obviously shares the same religious beliefs, nevertheless steer clear of conversations that have any semblance of spiritual undertones, even though the physicians may actually pray for them privately at a later time. Through the years, I have found that most patients appreciate knowing when their physician shares their belief system; frequently, patients even seek out physicians they know believe what they believe.

In addition, sometimes physicians feel uncomfortable discussing beliefs with colleagues, fearing we may be perceived as religious fanatics. When I Iived in Memphis and desperately wanted to move to the East Coast to start a family, I had a phone interview with a physician for a job I really wanted. All was going well until he asked a question I will never forget: What I would miss most about going from a private practice to an HMO (if he chose to hire me)? I immediately knew the answer: the freedom to pray with my patients. I felt compelled to answer the question, all the while fearing I may miss out on that job that I wanted so desperately.

To my surprise, my answer was not a turnoff to him at all. As a matter of fact, he told me I was free to pray with my HMO patients if they asked me to, although, again, prudence was warranted. Years ago, he thanked me for being so open with him because it helped him come out of his shell, and he started praying more openly with his patients.

I have even had a close family member request that his surgeon pray with him before spine surgery; the surgeon did pray with him in the OR prior to his being given anesthesia.

Most studies on spirituality and medicines show that patients welcome their health care professionals’ inquiries about their spiritual concerns, and they benefit from such discussions with their physicians. Up-To-Date has an article entitled "Religion, Spirituality, and End-of-Life Care." In it, the authors delve into a variety of aspects of the patient-physician spiritual connection, and provide numerous resources for further reading.

A physician should not violate the trust and ethics of the physician-patient relationship by coercing patients to pray with them against their will. But the authors do acknowledge the appropriateness of physicians’ praying with their patients when they are asked to do so, and when physicians do not feel coerced themselves.

The power of spirituality in patient-physician relationships is gaining more and more acceptance over time. Duke University, the University of California, San Francisco, and other major institutions have even posted videos on YouTube regarding health care professionals and their patients’ spirituality. If you thought that embracing your patients on a higher level is radical, it may be time to rethink things.

Dr. Hester is a hospitalist at Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

When I was in medical school, there was a very popular book called "The House of God." It dealt with the way doctors can sometimes elevate themselves to the level of a deity in their minds. But although physicians are highly trained professionals, we do not really have the final say in life. We have all pronounced dead rich patients, poor patients, happy patients, and sad patients. And one thing is for sure: No matter who we are, we all will meet the same fate one day. Frequently, patients are far more in tune to this reality than we are.

A Gallup poll, conducted in June of 2011, found that 92% of Americans believe in God. Among those with at least some college education, 93% believe in God; 94% of those who graduated college believe, and 87% of those with postgraduate training were found to believe in a deity.

©Amanda Rohde/iStockphoto.com

One thing that makes America great is that we each have the freedom to worship – or not worship – as we choose, and even among the majority of us who believe in God, there is a wide range of beliefs. Although many physicians may feel uncomfortable "mixing science and religion," I believe we do our patients a disservice when we refuse to acknowledge their feelings or pooh-pooh their beliefs.

We have all had patients whose prior doctors gave them 3-6 months to live – about 20-30 years ago, that is. And then there were those patients who had unwavering faith despite all odds, and even had family members and clergy come to pray with them, and did exceptionally well, despite our grim prognoses.

I suspect that there are several reasons physicians shy away from spirituality. One reason is that we are afraid that our words could be misconstrued as somehow unethical, and in certain situations, they may be. As in most things, prudence is in order. However, only the rare physician would use the vulnerability of sick patients to try to convert them to religion.

At the other end of the spectrum, we find many physicians who, when faced with a patient who obviously shares the same religious beliefs, nevertheless steer clear of conversations that have any semblance of spiritual undertones, even though the physicians may actually pray for them privately at a later time. Through the years, I have found that most patients appreciate knowing when their physician shares their belief system; frequently, patients even seek out physicians they know believe what they believe.

In addition, sometimes physicians feel uncomfortable discussing beliefs with colleagues, fearing we may be perceived as religious fanatics. When I Iived in Memphis and desperately wanted to move to the East Coast to start a family, I had a phone interview with a physician for a job I really wanted. All was going well until he asked a question I will never forget: What I would miss most about going from a private practice to an HMO (if he chose to hire me)? I immediately knew the answer: the freedom to pray with my patients. I felt compelled to answer the question, all the while fearing I may miss out on that job that I wanted so desperately.

To my surprise, my answer was not a turnoff to him at all. As a matter of fact, he told me I was free to pray with my HMO patients if they asked me to, although, again, prudence was warranted. Years ago, he thanked me for being so open with him because it helped him come out of his shell, and he started praying more openly with his patients.

I have even had a close family member request that his surgeon pray with him before spine surgery; the surgeon did pray with him in the OR prior to his being given anesthesia.

Most studies on spirituality and medicines show that patients welcome their health care professionals’ inquiries about their spiritual concerns, and they benefit from such discussions with their physicians. Up-To-Date has an article entitled "Religion, Spirituality, and End-of-Life Care." In it, the authors delve into a variety of aspects of the patient-physician spiritual connection, and provide numerous resources for further reading.

A physician should not violate the trust and ethics of the physician-patient relationship by coercing patients to pray with them against their will. But the authors do acknowledge the appropriateness of physicians’ praying with their patients when they are asked to do so, and when physicians do not feel coerced themselves.

The power of spirituality in patient-physician relationships is gaining more and more acceptance over time. Duke University, the University of California, San Francisco, and other major institutions have even posted videos on YouTube regarding health care professionals and their patients’ spirituality. If you thought that embracing your patients on a higher level is radical, it may be time to rethink things.

Dr. Hester is a hospitalist at Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

When I was in medical school, there was a very popular book called "The House of God." It dealt with the way doctors can sometimes elevate themselves to the level of a deity in their minds. But although physicians are highly trained professionals, we do not really have the final say in life. We have all pronounced dead rich patients, poor patients, happy patients, and sad patients. And one thing is for sure: No matter who we are, we all will meet the same fate one day. Frequently, patients are far more in tune to this reality than we are.

A Gallup poll, conducted in June of 2011, found that 92% of Americans believe in God. Among those with at least some college education, 93% believe in God; 94% of those who graduated college believe, and 87% of those with postgraduate training were found to believe in a deity.

©Amanda Rohde/iStockphoto.com

One thing that makes America great is that we each have the freedom to worship – or not worship – as we choose, and even among the majority of us who believe in God, there is a wide range of beliefs. Although many physicians may feel uncomfortable "mixing science and religion," I believe we do our patients a disservice when we refuse to acknowledge their feelings or pooh-pooh their beliefs.

We have all had patients whose prior doctors gave them 3-6 months to live – about 20-30 years ago, that is. And then there were those patients who had unwavering faith despite all odds, and even had family members and clergy come to pray with them, and did exceptionally well, despite our grim prognoses.

I suspect that there are several reasons physicians shy away from spirituality. One reason is that we are afraid that our words could be misconstrued as somehow unethical, and in certain situations, they may be. As in most things, prudence is in order. However, only the rare physician would use the vulnerability of sick patients to try to convert them to religion.

At the other end of the spectrum, we find many physicians who, when faced with a patient who obviously shares the same religious beliefs, nevertheless steer clear of conversations that have any semblance of spiritual undertones, even though the physicians may actually pray for them privately at a later time. Through the years, I have found that most patients appreciate knowing when their physician shares their belief system; frequently, patients even seek out physicians they know believe what they believe.

In addition, sometimes physicians feel uncomfortable discussing beliefs with colleagues, fearing we may be perceived as religious fanatics. When I Iived in Memphis and desperately wanted to move to the East Coast to start a family, I had a phone interview with a physician for a job I really wanted. All was going well until he asked a question I will never forget: What I would miss most about going from a private practice to an HMO (if he chose to hire me)? I immediately knew the answer: the freedom to pray with my patients. I felt compelled to answer the question, all the while fearing I may miss out on that job that I wanted so desperately.

To my surprise, my answer was not a turnoff to him at all. As a matter of fact, he told me I was free to pray with my HMO patients if they asked me to, although, again, prudence was warranted. Years ago, he thanked me for being so open with him because it helped him come out of his shell, and he started praying more openly with his patients.

I have even had a close family member request that his surgeon pray with him before spine surgery; the surgeon did pray with him in the OR prior to his being given anesthesia.

Most studies on spirituality and medicines show that patients welcome their health care professionals’ inquiries about their spiritual concerns, and they benefit from such discussions with their physicians. Up-To-Date has an article entitled "Religion, Spirituality, and End-of-Life Care." In it, the authors delve into a variety of aspects of the patient-physician spiritual connection, and provide numerous resources for further reading.

A physician should not violate the trust and ethics of the physician-patient relationship by coercing patients to pray with them against their will. But the authors do acknowledge the appropriateness of physicians’ praying with their patients when they are asked to do so, and when physicians do not feel coerced themselves.

The power of spirituality in patient-physician relationships is gaining more and more acceptance over time. Duke University, the University of California, San Francisco, and other major institutions have even posted videos on YouTube regarding health care professionals and their patients’ spirituality. If you thought that embracing your patients on a higher level is radical, it may be time to rethink things.

Dr. Hester is a hospitalist at Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Access to quality health care should be a right of every American citizen, not a privilege afforded to those who are poor enough to qualify for government assistance or fortunate enough to have the financial means to acquire it on their own or through their employer.

The Patient Protection and Affordable Care Act (ACA), was signed into law 2 years ago, a after decades of multiple attempts and multiple failed efforts to revamp America’s out-of-control health care system, and now many of us are watching closely as the U.S. Supreme Court weighs the constitutionality of an individual mandate for those who lack health insurance to purchase it or pay a penalty. In addition to many other important provisions, the ACA also reforms certain aspects of how private health insurance companies conduct business, such as their requirement to increase insurance coverage for the millions of Americans with a pre-existing illness.

© Cheryl Casey - Fotolia.com

For a moment, roll back the clock to 1776 when the Declaration of Independence was signed. It states: "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness."

We were promised basic rights. How is the right to live with dignity and minimal (preventable) suffering not deemed important unless one falls within a certain income bracket? While it is certain that we are not all going to agree on any one way to reform health care, we have to start somewhere. No solution is perfect, and we will most certainly have to tweak things along the way. But we cannot afford to wipe out the current law and start from scratch. The 30 million Americans who will soon have access to quality medical care under the ACA deserve – no, they have the right to expect – this country to protect their unalienable right to life! How can they be safe and happy when they are forced to suffer needlessly?

When I was a struggling college student, working two, sometimes three jobs to stay afloat (and still unable to afford much more than spaghetti topped with ketchup for dinner) there was absolutely no way I could have purchased health insurance. So, had I been injured in a car wreck, or, God forbid, been diagnosed with a serious illness, what would have happened to me? I was able, willing, and eager to become a productive member of society, but I was just one step away from total devastation, as are millions of Americans today.

My little girl is in day care and seems to bring home all the germs she can find. Recently, she had severe conjunctivitis with pus literally pouring out of both eyes. Every parent’s worst nightmare is watching his or her child suffer. As I watched her struggle through this illness, I grieved for all the mothers (and fathers) who watch their children suffer and know that even if they go to the emergency department for treatment, once they leave, they will not be able to afford the medication or follow-up visits required to optimize the outcome. Likewise, there are countless adults who watch their parents suffer, and sometimes die prematurely, simply because they lack the financial resources.

Time will tell what the Supreme Court decides about the ACA, but it appears that at least the personal mandate for health insurance may be in grave danger of repeal. News media, including CNN, have reported that the members of conservative majority on the bench are giving early indications that they may vote to repeal the personal mandate.

If this happens, the next question becomes: Will the entire ACA implode, forcing us to start from scratch with the possibility that it may be years before this vital debate on every citizen’s right to quality health care is resolved, or will it every really be resolved?

Is the status quo acceptable? Certainly it is, at least for some individuals with big bank accounts who will never watch loved ones suffer and die because they lack resources.

For the rest of us, I propose we do all we can to seek justice, love mercy, and walk humbly, for no one knows what tomorrow may bring, and one day we could be among the ranks of the uninsured or underinsured.

Dr. A. Maria Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

** This item has been corrected to say that the ACA law was signed 2 years ago.

Access to quality health care should be a right of every American citizen, not a privilege afforded to those who are poor enough to qualify for government assistance or fortunate enough to have the financial means to acquire it on their own or through their employer.

The Patient Protection and Affordable Care Act (ACA), was signed into law 2 years ago, a after decades of multiple attempts and multiple failed efforts to revamp America’s out-of-control health care system, and now many of us are watching closely as the U.S. Supreme Court weighs the constitutionality of an individual mandate for those who lack health insurance to purchase it or pay a penalty. In addition to many other important provisions, the ACA also reforms certain aspects of how private health insurance companies conduct business, such as their requirement to increase insurance coverage for the millions of Americans with a pre-existing illness.

© Cheryl Casey - Fotolia.com

For a moment, roll back the clock to 1776 when the Declaration of Independence was signed. It states: "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness."

We were promised basic rights. How is the right to live with dignity and minimal (preventable) suffering not deemed important unless one falls within a certain income bracket? While it is certain that we are not all going to agree on any one way to reform health care, we have to start somewhere. No solution is perfect, and we will most certainly have to tweak things along the way. But we cannot afford to wipe out the current law and start from scratch. The 30 million Americans who will soon have access to quality medical care under the ACA deserve – no, they have the right to expect – this country to protect their unalienable right to life! How can they be safe and happy when they are forced to suffer needlessly?

When I was a struggling college student, working two, sometimes three jobs to stay afloat (and still unable to afford much more than spaghetti topped with ketchup for dinner) there was absolutely no way I could have purchased health insurance. So, had I been injured in a car wreck, or, God forbid, been diagnosed with a serious illness, what would have happened to me? I was able, willing, and eager to become a productive member of society, but I was just one step away from total devastation, as are millions of Americans today.

My little girl is in day care and seems to bring home all the germs she can find. Recently, she had severe conjunctivitis with pus literally pouring out of both eyes. Every parent’s worst nightmare is watching his or her child suffer. As I watched her struggle through this illness, I grieved for all the mothers (and fathers) who watch their children suffer and know that even if they go to the emergency department for treatment, once they leave, they will not be able to afford the medication or follow-up visits required to optimize the outcome. Likewise, there are countless adults who watch their parents suffer, and sometimes die prematurely, simply because they lack the financial resources.

Time will tell what the Supreme Court decides about the ACA, but it appears that at least the personal mandate for health insurance may be in grave danger of repeal. News media, including CNN, have reported that the members of conservative majority on the bench are giving early indications that they may vote to repeal the personal mandate.

If this happens, the next question becomes: Will the entire ACA implode, forcing us to start from scratch with the possibility that it may be years before this vital debate on every citizen’s right to quality health care is resolved, or will it every really be resolved?

Is the status quo acceptable? Certainly it is, at least for some individuals with big bank accounts who will never watch loved ones suffer and die because they lack resources.

For the rest of us, I propose we do all we can to seek justice, love mercy, and walk humbly, for no one knows what tomorrow may bring, and one day we could be among the ranks of the uninsured or underinsured.

Dr. A. Maria Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

** This item has been corrected to say that the ACA law was signed 2 years ago.

Access to quality health care should be a right of every American citizen, not a privilege afforded to those who are poor enough to qualify for government assistance or fortunate enough to have the financial means to acquire it on their own or through their employer.

The Patient Protection and Affordable Care Act (ACA), was signed into law 2 years ago, a after decades of multiple attempts and multiple failed efforts to revamp America’s out-of-control health care system, and now many of us are watching closely as the U.S. Supreme Court weighs the constitutionality of an individual mandate for those who lack health insurance to purchase it or pay a penalty. In addition to many other important provisions, the ACA also reforms certain aspects of how private health insurance companies conduct business, such as their requirement to increase insurance coverage for the millions of Americans with a pre-existing illness.

© Cheryl Casey - Fotolia.com

For a moment, roll back the clock to 1776 when the Declaration of Independence was signed. It states: "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness."

We were promised basic rights. How is the right to live with dignity and minimal (preventable) suffering not deemed important unless one falls within a certain income bracket? While it is certain that we are not all going to agree on any one way to reform health care, we have to start somewhere. No solution is perfect, and we will most certainly have to tweak things along the way. But we cannot afford to wipe out the current law and start from scratch. The 30 million Americans who will soon have access to quality medical care under the ACA deserve – no, they have the right to expect – this country to protect their unalienable right to life! How can they be safe and happy when they are forced to suffer needlessly?

When I was a struggling college student, working two, sometimes three jobs to stay afloat (and still unable to afford much more than spaghetti topped with ketchup for dinner) there was absolutely no way I could have purchased health insurance. So, had I been injured in a car wreck, or, God forbid, been diagnosed with a serious illness, what would have happened to me? I was able, willing, and eager to become a productive member of society, but I was just one step away from total devastation, as are millions of Americans today.

My little girl is in day care and seems to bring home all the germs she can find. Recently, she had severe conjunctivitis with pus literally pouring out of both eyes. Every parent’s worst nightmare is watching his or her child suffer. As I watched her struggle through this illness, I grieved for all the mothers (and fathers) who watch their children suffer and know that even if they go to the emergency department for treatment, once they leave, they will not be able to afford the medication or follow-up visits required to optimize the outcome. Likewise, there are countless adults who watch their parents suffer, and sometimes die prematurely, simply because they lack the financial resources.

Time will tell what the Supreme Court decides about the ACA, but it appears that at least the personal mandate for health insurance may be in grave danger of repeal. News media, including CNN, have reported that the members of conservative majority on the bench are giving early indications that they may vote to repeal the personal mandate.

If this happens, the next question becomes: Will the entire ACA implode, forcing us to start from scratch with the possibility that it may be years before this vital debate on every citizen’s right to quality health care is resolved, or will it every really be resolved?

Is the status quo acceptable? Certainly it is, at least for some individuals with big bank accounts who will never watch loved ones suffer and die because they lack resources.

For the rest of us, I propose we do all we can to seek justice, love mercy, and walk humbly, for no one knows what tomorrow may bring, and one day we could be among the ranks of the uninsured or underinsured.

Dr. A. Maria Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

** This item has been corrected to say that the ACA law was signed 2 years ago.

Imagine the day patients will actually become significant partners in the medical care they receive. I have long held that true health care reform will only be effective if patients are equipped with tools to collaborate effectively in their own care, and the just-released 2012 SAFE CARE Patient Safety Education Program is a tremendous step in the right direction.

Launching during Patient Safety Awareness Week (March 4-10), this program is designed to help health care organizations educate patients on ways to prevent medical errors. It is long overdue. It includes posters for hospital rooms that encourage patients and their families to watch safety videos on their smartphones simply by texting the word "SAFE" to receive a link to the Safe Care safety video library. Alternatively, they can point their smartphones at a QR code on the poster.

The videos include topics such as avoiding medication errors and patient falls and preventing infections. (With all the resistant organisms we are fighting in 2012, we can use all the help we can get.)

"This campaign gives patients the information they need to speak up and be active participants in their health care," said Cathy Barry-Ipema, chief communications officer at the Joint Commission. The program, a partnership of the Joint Commission, Kimberly-Clark, and Safe Care Campaign, is offered free to hospitals.

Naturally, all patients will avail themselves of these videos, but those who do – and there will be plenty – will gain a wealth of information, some of which may prove to be lifesaving. Every one of us has had those patients who can’t seem to stay off their smartphones even long enough for us to examine them. And then there are the very attentive family members who remain faithfully at the bedside during their loved ones’ entire hospital stay, ever seeking additional useful information. These two groups are just the tip of the iceberg, as I suspect many others will view the videos for other reasons, including curiosity and boredom. Regardless of the reason, they will all be exposed to valuable tips to help make each hospitalization safer, which is the bottom line.

For hospitalists, improving quality of care and patient safety are core competencies, central in a day’s work. Any new tool that is innovative, well developed, and free should be heartily welcomed.

America has always had a very paternalistic health care system. Now it is time to bring the receivers of health care into the inner circle. Patients truly should be the center of the health care team. Doctors are not the ones with inflated hospital bills and life-threatening ICU stays when things go wrong. Patients are.

Undoubtedly, "a little information can be dangerous" in certain cases, and there will most certainly be instances in which patients and their loved ones may inappropriately challenge or second-guess a physician or nurse after having watched a video, but I believe these cases will be the exception, not the rule. The potential to improve patient care, I believe, is dramatic, and I applaud the efforts of the program’s creators.

When I was a third-year medical student, I cared for a breast cancer patient who had waited until the mass became infected before seeking any medical attention. It was too late to treat her cancer, but her case was a memorable moment in my quest to empower patients. I started writing my first patient empowerment book while in medical school, and I published a second one several years later. Then I moved on to writing health articles and developing online patient education outlets, as well as a talking personal health record on a USB flash drive.

Having spent more than 20 years working to enlighten patients, I am simply ecstatic to see others share that passion.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center. This is the first entry in her new blog, "Teachable Moments."

Imagine the day patients will actually become significant partners in the medical care they receive. I have long held that true health care reform will only be effective if patients are equipped with tools to collaborate effectively in their own care, and the just-released 2012 SAFE CARE Patient Safety Education Program is a tremendous step in the right direction.

Launching during Patient Safety Awareness Week (March 4-10), this program is designed to help health care organizations educate patients on ways to prevent medical errors. It is long overdue. It includes posters for hospital rooms that encourage patients and their families to watch safety videos on their smartphones simply by texting the word "SAFE" to receive a link to the Safe Care safety video library. Alternatively, they can point their smartphones at a QR code on the poster.

The videos include topics such as avoiding medication errors and patient falls and preventing infections. (With all the resistant organisms we are fighting in 2012, we can use all the help we can get.)

"This campaign gives patients the information they need to speak up and be active participants in their health care," said Cathy Barry-Ipema, chief communications officer at the Joint Commission. The program, a partnership of the Joint Commission, Kimberly-Clark, and Safe Care Campaign, is offered free to hospitals.

Naturally, all patients will avail themselves of these videos, but those who do – and there will be plenty – will gain a wealth of information, some of which may prove to be lifesaving. Every one of us has had those patients who can’t seem to stay off their smartphones even long enough for us to examine them. And then there are the very attentive family members who remain faithfully at the bedside during their loved ones’ entire hospital stay, ever seeking additional useful information. These two groups are just the tip of the iceberg, as I suspect many others will view the videos for other reasons, including curiosity and boredom. Regardless of the reason, they will all be exposed to valuable tips to help make each hospitalization safer, which is the bottom line.

For hospitalists, improving quality of care and patient safety are core competencies, central in a day’s work. Any new tool that is innovative, well developed, and free should be heartily welcomed.

America has always had a very paternalistic health care system. Now it is time to bring the receivers of health care into the inner circle. Patients truly should be the center of the health care team. Doctors are not the ones with inflated hospital bills and life-threatening ICU stays when things go wrong. Patients are.

Undoubtedly, "a little information can be dangerous" in certain cases, and there will most certainly be instances in which patients and their loved ones may inappropriately challenge or second-guess a physician or nurse after having watched a video, but I believe these cases will be the exception, not the rule. The potential to improve patient care, I believe, is dramatic, and I applaud the efforts of the program’s creators.

When I was a third-year medical student, I cared for a breast cancer patient who had waited until the mass became infected before seeking any medical attention. It was too late to treat her cancer, but her case was a memorable moment in my quest to empower patients. I started writing my first patient empowerment book while in medical school, and I published a second one several years later. Then I moved on to writing health articles and developing online patient education outlets, as well as a talking personal health record on a USB flash drive.

Having spent more than 20 years working to enlighten patients, I am simply ecstatic to see others share that passion.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center. This is the first entry in her new blog, "Teachable Moments."

Imagine the day patients will actually become significant partners in the medical care they receive. I have long held that true health care reform will only be effective if patients are equipped with tools to collaborate effectively in their own care, and the just-released 2012 SAFE CARE Patient Safety Education Program is a tremendous step in the right direction.

Launching during Patient Safety Awareness Week (March 4-10), this program is designed to help health care organizations educate patients on ways to prevent medical errors. It is long overdue. It includes posters for hospital rooms that encourage patients and their families to watch safety videos on their smartphones simply by texting the word "SAFE" to receive a link to the Safe Care safety video library. Alternatively, they can point their smartphones at a QR code on the poster.

The videos include topics such as avoiding medication errors and patient falls and preventing infections. (With all the resistant organisms we are fighting in 2012, we can use all the help we can get.)

"This campaign gives patients the information they need to speak up and be active participants in their health care," said Cathy Barry-Ipema, chief communications officer at the Joint Commission. The program, a partnership of the Joint Commission, Kimberly-Clark, and Safe Care Campaign, is offered free to hospitals.

Naturally, all patients will avail themselves of these videos, but those who do – and there will be plenty – will gain a wealth of information, some of which may prove to be lifesaving. Every one of us has had those patients who can’t seem to stay off their smartphones even long enough for us to examine them. And then there are the very attentive family members who remain faithfully at the bedside during their loved ones’ entire hospital stay, ever seeking additional useful information. These two groups are just the tip of the iceberg, as I suspect many others will view the videos for other reasons, including curiosity and boredom. Regardless of the reason, they will all be exposed to valuable tips to help make each hospitalization safer, which is the bottom line.

For hospitalists, improving quality of care and patient safety are core competencies, central in a day’s work. Any new tool that is innovative, well developed, and free should be heartily welcomed.

America has always had a very paternalistic health care system. Now it is time to bring the receivers of health care into the inner circle. Patients truly should be the center of the health care team. Doctors are not the ones with inflated hospital bills and life-threatening ICU stays when things go wrong. Patients are.

Undoubtedly, "a little information can be dangerous" in certain cases, and there will most certainly be instances in which patients and their loved ones may inappropriately challenge or second-guess a physician or nurse after having watched a video, but I believe these cases will be the exception, not the rule. The potential to improve patient care, I believe, is dramatic, and I applaud the efforts of the program’s creators.

When I was a third-year medical student, I cared for a breast cancer patient who had waited until the mass became infected before seeking any medical attention. It was too late to treat her cancer, but her case was a memorable moment in my quest to empower patients. I started writing my first patient empowerment book while in medical school, and I published a second one several years later. Then I moved on to writing health articles and developing online patient education outlets, as well as a talking personal health record on a USB flash drive.

Having spent more than 20 years working to enlighten patients, I am simply ecstatic to see others share that passion.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center. This is the first entry in her new blog, "Teachable Moments."

Alternative medicine is a booming business, and for good reason. Conventional medications are often wrought with unpleasant, sometimes serious side effects, and they often come with a high price tag. And then there are the drug recalls that occur after multiple people have nearly died from using them. No wonder the public is wary of prescription drugs.

According to the Centers for Disease Control and Prevention, the 2007 National Health Interview Survey Alternative Medicine Supplement noted that close to 18% of adults in the United States had used natural products in 2006. Among the natural products used by Americans, fish oil supplements lead the pack, followed by Echinacea at 19.8%. Other popular products were flaxseed (15.9%), ginseng (14.1%), and ginkgo biloba (11.3%).

As a result of the high side-effect profile of many medications, as well as the uncertainty of their safety, many have turned to natural solutions to heal their ailments. A recent article in the New England Journal of Medicine stated that each year, Americans spend close to $30 billion on supplements believing that since they are natural, they are safe, as well as effective and various supplements are used by over 100 million Americans (N. Engl. J. Med. 2012;366:389-391). I humbly admit that early in my career, I was purely focused on the tried-and-true, gold standard of the randomized, placebo-controlled trial. If a treatment did not have the credentials I thought it should have, I didn’t recommend it and often discouraged my patients from using it. However, over the years, I wised up. Now, I am a true believer in certain alternative therapies and buy them regularly. For instance, I have found rose hips tea to be extremely relaxing after a long day at work. It appears to calm the entire world around me and gives me no side effects whatsoever.

Photo (c) Orchidpoet/iStockphoto

Many of our patients use natural remedies too, but do not mention them, thinking either they are not important or that we physicians will turn our noses up at their use. However, it is important for us to know everything they are taking, since some alternative treatments have the potential to interfere with our treatments and cause their own side effects as well.

For instance, Chinese cinnamon (also called cassia cinnamon) contains coumarin, which could be problematic in patients already on Coumadin or those who are risk of bleeding from other causes. Açaí fruit pulp has been tested as a contrast agent for MRI of the GI tract, and can impact MRI results. Black cohosh can cause GI upset, headache, rash, and even liver failure.

These are only a few potential side effects of commonly used supplements.

We should ask our patients if they take any supplements, and if they do, we should offer educated guidance as well as encourage them to visit the National Center for Complementary and Alternative Medicine online to learn more about these supplements. They, too, need to understand exactly what they are putting in their bodies. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

Alternative medicine is a booming business, and for good reason. Conventional medications are often wrought with unpleasant, sometimes serious side effects, and they often come with a high price tag. And then there are the drug recalls that occur after multiple people have nearly died from using them. No wonder the public is wary of prescription drugs.

According to the Centers for Disease Control and Prevention, the 2007 National Health Interview Survey Alternative Medicine Supplement noted that close to 18% of adults in the United States had used natural products in 2006. Among the natural products used by Americans, fish oil supplements lead the pack, followed by Echinacea at 19.8%. Other popular products were flaxseed (15.9%), ginseng (14.1%), and ginkgo biloba (11.3%).

As a result of the high side-effect profile of many medications, as well as the uncertainty of their safety, many have turned to natural solutions to heal their ailments. A recent article in the New England Journal of Medicine stated that each year, Americans spend close to $30 billion on supplements believing that since they are natural, they are safe, as well as effective and various supplements are used by over 100 million Americans (N. Engl. J. Med. 2012;366:389-391). I humbly admit that early in my career, I was purely focused on the tried-and-true, gold standard of the randomized, placebo-controlled trial. If a treatment did not have the credentials I thought it should have, I didn’t recommend it and often discouraged my patients from using it. However, over the years, I wised up. Now, I am a true believer in certain alternative therapies and buy them regularly. For instance, I have found rose hips tea to be extremely relaxing after a long day at work. It appears to calm the entire world around me and gives me no side effects whatsoever.

Photo (c) Orchidpoet/iStockphoto

Many of our patients use natural remedies too, but do not mention them, thinking either they are not important or that we physicians will turn our noses up at their use. However, it is important for us to know everything they are taking, since some alternative treatments have the potential to interfere with our treatments and cause their own side effects as well.

For instance, Chinese cinnamon (also called cassia cinnamon) contains coumarin, which could be problematic in patients already on Coumadin or those who are risk of bleeding from other causes. Açaí fruit pulp has been tested as a contrast agent for MRI of the GI tract, and can impact MRI results. Black cohosh can cause GI upset, headache, rash, and even liver failure.

These are only a few potential side effects of commonly used supplements.

We should ask our patients if they take any supplements, and if they do, we should offer educated guidance as well as encourage them to visit the National Center for Complementary and Alternative Medicine online to learn more about these supplements. They, too, need to understand exactly what they are putting in their bodies. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

Alternative medicine is a booming business, and for good reason. Conventional medications are often wrought with unpleasant, sometimes serious side effects, and they often come with a high price tag. And then there are the drug recalls that occur after multiple people have nearly died from using them. No wonder the public is wary of prescription drugs.

According to the Centers for Disease Control and Prevention, the 2007 National Health Interview Survey Alternative Medicine Supplement noted that close to 18% of adults in the United States had used natural products in 2006. Among the natural products used by Americans, fish oil supplements lead the pack, followed by Echinacea at 19.8%. Other popular products were flaxseed (15.9%), ginseng (14.1%), and ginkgo biloba (11.3%).

As a result of the high side-effect profile of many medications, as well as the uncertainty of their safety, many have turned to natural solutions to heal their ailments. A recent article in the New England Journal of Medicine stated that each year, Americans spend close to $30 billion on supplements believing that since they are natural, they are safe, as well as effective and various supplements are used by over 100 million Americans (N. Engl. J. Med. 2012;366:389-391). I humbly admit that early in my career, I was purely focused on the tried-and-true, gold standard of the randomized, placebo-controlled trial. If a treatment did not have the credentials I thought it should have, I didn’t recommend it and often discouraged my patients from using it. However, over the years, I wised up. Now, I am a true believer in certain alternative therapies and buy them regularly. For instance, I have found rose hips tea to be extremely relaxing after a long day at work. It appears to calm the entire world around me and gives me no side effects whatsoever.

Photo (c) Orchidpoet/iStockphoto

Many of our patients use natural remedies too, but do not mention them, thinking either they are not important or that we physicians will turn our noses up at their use. However, it is important for us to know everything they are taking, since some alternative treatments have the potential to interfere with our treatments and cause their own side effects as well.

For instance, Chinese cinnamon (also called cassia cinnamon) contains coumarin, which could be problematic in patients already on Coumadin or those who are risk of bleeding from other causes. Açaí fruit pulp has been tested as a contrast agent for MRI of the GI tract, and can impact MRI results. Black cohosh can cause GI upset, headache, rash, and even liver failure.

These are only a few potential side effects of commonly used supplements.

We should ask our patients if they take any supplements, and if they do, we should offer educated guidance as well as encourage them to visit the National Center for Complementary and Alternative Medicine online to learn more about these supplements. They, too, need to understand exactly what they are putting in their bodies. 

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

It seems easier to explain to patients why they "don’t really need that antibiotic," thanks to the public health campaign on potential harm from, and the lack of efficacy of, antibiotics in certain situations such as viral infections. Yet, in the midst of this apparent meeting of the minds between doctors and patients, another superbug has emerged that is changing the game again.

A hypervirulent strain of Clostridium difficile, known as BI/NAP1/027, or NAP1 for short, has made the necessity of appropriate antibiotic prescribing more urgent than ever. According to Dr. Carolyn Gould, a medical epidemiologist in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention in Atlanta, this strain produces up to 15-20 times more toxin than other strains.

We all know about antibiotics, which wipe out a lot of normal bowel flora, and thus predispose to C. difficile. Even many patients realize that the use of antibiotics can lead to new infections, particularly among women, who frequently get yeast infections when taking antibiotics. Now, with current concerns that the widely used proton pump inhibitors also predispose to this condition, it will be even harder to control C. difficile infection rates. If a patient has been taking a proton pump inhibitor for a long time without a clear indication (sometimes it’s just because he/she is "used to taking it"), they should be given a trial off this medication. If they do well without it, fine. If not, it can always be resumed.

Photo courtesy CDC/D.Holdeman

Frustration is compounded in patients who get C. difficile again and again. And, naturally, their family members often become concerned that they, too, may come down with this potentially devastating infection. While we may not be able to completely eradicate this microorganism, we can help educate patients and their families about risk factors and help them avoid spreading the infection should they develop it.

Hygiene remains of paramount importance. It is well known that hand-washing, not alcohol scrubs, is the best way to minimize the transmission of C. difficile between patients. But there is much more. The Mayo Clinic initiated a project to cut the rate of C. difficile infections by asking its workers to simply wipe down high-touch areas with bleach wipes twice daily. This simple step all but eliminated infections in units that had been averaging five to seven infections per month. While there may not be a randomized controlled clinical trial to support using the same procedure at home, it stands to reason that when patients with C. difficile leave the hospital, cleaning appropriate surfaces in their homes with a bleach solution may help kill the organism in their homes as well, thus helping the patients as well as their families.

Infection control is an ever-moving target. But if we can take a few simple steps to hit the bulls-eye on occasion, we may actually help save lives.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. 

It seems easier to explain to patients why they "don’t really need that antibiotic," thanks to the public health campaign on potential harm from, and the lack of efficacy of, antibiotics in certain situations such as viral infections. Yet, in the midst of this apparent meeting of the minds between doctors and patients, another superbug has emerged that is changing the game again.

A hypervirulent strain of Clostridium difficile, known as BI/NAP1/027, or NAP1 for short, has made the necessity of appropriate antibiotic prescribing more urgent than ever. According to Dr. Carolyn Gould, a medical epidemiologist in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention in Atlanta, this strain produces up to 15-20 times more toxin than other strains.

We all know about antibiotics, which wipe out a lot of normal bowel flora, and thus predispose to C. difficile. Even many patients realize that the use of antibiotics can lead to new infections, particularly among women, who frequently get yeast infections when taking antibiotics. Now, with current concerns that the widely used proton pump inhibitors also predispose to this condition, it will be even harder to control C. difficile infection rates. If a patient has been taking a proton pump inhibitor for a long time without a clear indication (sometimes it’s just because he/she is "used to taking it"), they should be given a trial off this medication. If they do well without it, fine. If not, it can always be resumed.

Photo courtesy CDC/D.Holdeman

Frustration is compounded in patients who get C. difficile again and again. And, naturally, their family members often become concerned that they, too, may come down with this potentially devastating infection. While we may not be able to completely eradicate this microorganism, we can help educate patients and their families about risk factors and help them avoid spreading the infection should they develop it.

Hygiene remains of paramount importance. It is well known that hand-washing, not alcohol scrubs, is the best way to minimize the transmission of C. difficile between patients. But there is much more. The Mayo Clinic initiated a project to cut the rate of C. difficile infections by asking its workers to simply wipe down high-touch areas with bleach wipes twice daily. This simple step all but eliminated infections in units that had been averaging five to seven infections per month. While there may not be a randomized controlled clinical trial to support using the same procedure at home, it stands to reason that when patients with C. difficile leave the hospital, cleaning appropriate surfaces in their homes with a bleach solution may help kill the organism in their homes as well, thus helping the patients as well as their families.

Infection control is an ever-moving target. But if we can take a few simple steps to hit the bulls-eye on occasion, we may actually help save lives.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. 

It seems easier to explain to patients why they "don’t really need that antibiotic," thanks to the public health campaign on potential harm from, and the lack of efficacy of, antibiotics in certain situations such as viral infections. Yet, in the midst of this apparent meeting of the minds between doctors and patients, another superbug has emerged that is changing the game again.

A hypervirulent strain of Clostridium difficile, known as BI/NAP1/027, or NAP1 for short, has made the necessity of appropriate antibiotic prescribing more urgent than ever. According to Dr. Carolyn Gould, a medical epidemiologist in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention in Atlanta, this strain produces up to 15-20 times more toxin than other strains.

We all know about antibiotics, which wipe out a lot of normal bowel flora, and thus predispose to C. difficile. Even many patients realize that the use of antibiotics can lead to new infections, particularly among women, who frequently get yeast infections when taking antibiotics. Now, with current concerns that the widely used proton pump inhibitors also predispose to this condition, it will be even harder to control C. difficile infection rates. If a patient has been taking a proton pump inhibitor for a long time without a clear indication (sometimes it’s just because he/she is "used to taking it"), they should be given a trial off this medication. If they do well without it, fine. If not, it can always be resumed.

Photo courtesy CDC/D.Holdeman

Frustration is compounded in patients who get C. difficile again and again. And, naturally, their family members often become concerned that they, too, may come down with this potentially devastating infection. While we may not be able to completely eradicate this microorganism, we can help educate patients and their families about risk factors and help them avoid spreading the infection should they develop it.

Hygiene remains of paramount importance. It is well known that hand-washing, not alcohol scrubs, is the best way to minimize the transmission of C. difficile between patients. But there is much more. The Mayo Clinic initiated a project to cut the rate of C. difficile infections by asking its workers to simply wipe down high-touch areas with bleach wipes twice daily. This simple step all but eliminated infections in units that had been averaging five to seven infections per month. While there may not be a randomized controlled clinical trial to support using the same procedure at home, it stands to reason that when patients with C. difficile leave the hospital, cleaning appropriate surfaces in their homes with a bleach solution may help kill the organism in their homes as well, thus helping the patients as well as their families.

Infection control is an ever-moving target. But if we can take a few simple steps to hit the bulls-eye on occasion, we may actually help save lives.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. 

If you are like most physicians, there is a group of drugs that you prescribe regularly and feel very comfortable with. While deep down we know they are not always safe, we use them so often, we may not think twice about ordering them.

Then there are those medications that we tend to shy away from – drugs like immunosuppressants, psychotropics, and others that are best prescribed by specialists familiar with their side effects. But, truth be told, it is our so-called "safe" drugs that land patients in the emergency department most of the time.

A recent article in the New England Journal of Medicine (titled Emergency Hospitalizations for Adverse Drug Events in Older Americans) cites four medications or medication classes as being responsible for 67% of hospitalizations related to adverse drug reactions (N. Engl. J. Med. 2011;365:2002-12). Specifically, warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents were implicated in 67% of these hospitalizations. Conversely, a mere 1.2% of emergency medication-related admissions resulted from would be considered high-risk medications.

Most of us have admitted sweet little elderly ladies with atrial fibrillation who presents with black stools and a hematocrit in the teens. In some cases, they got confused an accidentally doubled up on a few doses of warfarin or received a medication that prolonged the INR. Add on occasional antiplatelet agents prescribed for recent cardiac stents and you have a recipe for disaster.

Then there are patients who have a new-onset seizure related to severe hypoglycemia. A few days of diarrhea caused dehydration with a resultant decline in renal function that makes the oral hypoglycemic agent they take hang around longer, and voila: a blood sugar of 30! And don’t forget that patient who’s been a little depressed and not eating much, but dutifully continues to take his insulin as prescribed.

The take-home lesson here is that we as physicians have a long way to go educating our patients:

• We should make sure that everyone we put on warfarin has a warfarin diet sheet explaining what their should be eating while on this medication.

Additionally, acute alcohol ingestion can increase the INR, while chronic daily consumption of alcohol increases metabolism of warfarin and can lower the INR, so we should counsel our patients accordingly.

Vitamin E, cranberry juice, and green tea have the potential to raise INR, as do CoQ10 and numerous commonly used herbs, such as ginseng, and ginger. Even horseradish, licorice, and omega-3 acids may affect the INR, so it is easy to see why so many people wind up in the ED with warfarin toxicity.

Patients should also be advised that since many medications have the potential to interact with warfarin, they should always check with their pharmacist or primary care doctor when prescribed a new medication, especially if it is prescribed by a specialist who might be less familiar warfarin interactions.

• We need to educate our patients on the significance of black, tarry stools. I can’t count the number of times patients have noticed black stools for more than a week and never reported it to their physician, thinking it was because of something they ate.

• People with diabetes should have an action plan on sick days and should know how to check their blood sugar regularly. While this is a typically deemed a primary care issue, there are situations in which it is clear that our patients will need an action plan immediately, such as directly after discharge.

The New England Journal of Medicine article also notes that more than 99,000 emergency hospitalizations for adverse drug events occurred each year from 2007 through 2009 for U.S. adults aged 65 years of age or older. Obviously, all physicians have a lot more educating to do.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like most physicians, there is a group of drugs that you prescribe regularly and feel very comfortable with. While deep down we know they are not always safe, we use them so often, we may not think twice about ordering them.

Then there are those medications that we tend to shy away from – drugs like immunosuppressants, psychotropics, and others that are best prescribed by specialists familiar with their side effects. But, truth be told, it is our so-called "safe" drugs that land patients in the emergency department most of the time.

A recent article in the New England Journal of Medicine (titled Emergency Hospitalizations for Adverse Drug Events in Older Americans) cites four medications or medication classes as being responsible for 67% of hospitalizations related to adverse drug reactions (N. Engl. J. Med. 2011;365:2002-12). Specifically, warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents were implicated in 67% of these hospitalizations. Conversely, a mere 1.2% of emergency medication-related admissions resulted from would be considered high-risk medications.

Most of us have admitted sweet little elderly ladies with atrial fibrillation who presents with black stools and a hematocrit in the teens. In some cases, they got confused an accidentally doubled up on a few doses of warfarin or received a medication that prolonged the INR. Add on occasional antiplatelet agents prescribed for recent cardiac stents and you have a recipe for disaster.

Then there are patients who have a new-onset seizure related to severe hypoglycemia. A few days of diarrhea caused dehydration with a resultant decline in renal function that makes the oral hypoglycemic agent they take hang around longer, and voila: a blood sugar of 30! And don’t forget that patient who’s been a little depressed and not eating much, but dutifully continues to take his insulin as prescribed.

The take-home lesson here is that we as physicians have a long way to go educating our patients:

• We should make sure that everyone we put on warfarin has a warfarin diet sheet explaining what their should be eating while on this medication.

Additionally, acute alcohol ingestion can increase the INR, while chronic daily consumption of alcohol increases metabolism of warfarin and can lower the INR, so we should counsel our patients accordingly.

Vitamin E, cranberry juice, and green tea have the potential to raise INR, as do CoQ10 and numerous commonly used herbs, such as ginseng, and ginger. Even horseradish, licorice, and omega-3 acids may affect the INR, so it is easy to see why so many people wind up in the ED with warfarin toxicity.

Patients should also be advised that since many medications have the potential to interact with warfarin, they should always check with their pharmacist or primary care doctor when prescribed a new medication, especially if it is prescribed by a specialist who might be less familiar warfarin interactions.

• We need to educate our patients on the significance of black, tarry stools. I can’t count the number of times patients have noticed black stools for more than a week and never reported it to their physician, thinking it was because of something they ate.

• People with diabetes should have an action plan on sick days and should know how to check their blood sugar regularly. While this is a typically deemed a primary care issue, there are situations in which it is clear that our patients will need an action plan immediately, such as directly after discharge.

The New England Journal of Medicine article also notes that more than 99,000 emergency hospitalizations for adverse drug events occurred each year from 2007 through 2009 for U.S. adults aged 65 years of age or older. Obviously, all physicians have a lot more educating to do.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like most physicians, there is a group of drugs that you prescribe regularly and feel very comfortable with. While deep down we know they are not always safe, we use them so often, we may not think twice about ordering them.

Then there are those medications that we tend to shy away from – drugs like immunosuppressants, psychotropics, and others that are best prescribed by specialists familiar with their side effects. But, truth be told, it is our so-called "safe" drugs that land patients in the emergency department most of the time.

A recent article in the New England Journal of Medicine (titled Emergency Hospitalizations for Adverse Drug Events in Older Americans) cites four medications or medication classes as being responsible for 67% of hospitalizations related to adverse drug reactions (N. Engl. J. Med. 2011;365:2002-12). Specifically, warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents were implicated in 67% of these hospitalizations. Conversely, a mere 1.2% of emergency medication-related admissions resulted from would be considered high-risk medications.

Most of us have admitted sweet little elderly ladies with atrial fibrillation who presents with black stools and a hematocrit in the teens. In some cases, they got confused an accidentally doubled up on a few doses of warfarin or received a medication that prolonged the INR. Add on occasional antiplatelet agents prescribed for recent cardiac stents and you have a recipe for disaster.

Then there are patients who have a new-onset seizure related to severe hypoglycemia. A few days of diarrhea caused dehydration with a resultant decline in renal function that makes the oral hypoglycemic agent they take hang around longer, and voila: a blood sugar of 30! And don’t forget that patient who’s been a little depressed and not eating much, but dutifully continues to take his insulin as prescribed.

The take-home lesson here is that we as physicians have a long way to go educating our patients:

• We should make sure that everyone we put on warfarin has a warfarin diet sheet explaining what their should be eating while on this medication.

Additionally, acute alcohol ingestion can increase the INR, while chronic daily consumption of alcohol increases metabolism of warfarin and can lower the INR, so we should counsel our patients accordingly.

Vitamin E, cranberry juice, and green tea have the potential to raise INR, as do CoQ10 and numerous commonly used herbs, such as ginseng, and ginger. Even horseradish, licorice, and omega-3 acids may affect the INR, so it is easy to see why so many people wind up in the ED with warfarin toxicity.

Patients should also be advised that since many medications have the potential to interact with warfarin, they should always check with their pharmacist or primary care doctor when prescribed a new medication, especially if it is prescribed by a specialist who might be less familiar warfarin interactions.

• We need to educate our patients on the significance of black, tarry stools. I can’t count the number of times patients have noticed black stools for more than a week and never reported it to their physician, thinking it was because of something they ate.

• People with diabetes should have an action plan on sick days and should know how to check their blood sugar regularly. While this is a typically deemed a primary care issue, there are situations in which it is clear that our patients will need an action plan immediately, such as directly after discharge.

The New England Journal of Medicine article also notes that more than 99,000 emergency hospitalizations for adverse drug events occurred each year from 2007 through 2009 for U.S. adults aged 65 years of age or older. Obviously, all physicians have a lot more educating to do.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.