A middle aged male was recently experiencing severe abdominal pain, subsequently prescribed three (3) medications in two (2) weeks from three (3) different sources (an Emergency Room, a primary care doctor, a Gastroenterologist). There was no diagnosis, no care coordination within an established plan of care, no thorough instruction in the medications, with the last prescription based on a guessed misdiagnosis which worsened his pain. One prescription was a steroid with the patient being instructed to take as he needed it; the second was an offering by the office secretary blindly asking if he wanted an Epipen when he called to actually speak with the physician for worsening abdominal pain, swelling and to discuss his lab work.
The common standard operating procedure (SOP) in medicine has become symptom and write a prescription, another symptom and write another prescription, etc. This SOP has lent to the opioid crisis, antibiotic resistance, as well as many other drugs being dispensed routinely with side effects causing secondary prescriptions for the side effects of the existing medications being taken.
Several variables cause the use of this SOP beginning with the lack to get a full, detailed history - taking time to speak with patients - to establish a diagnosis and then plan of care, determining if simple steps are first needed such as icing and therapy for pain before opioids, or to remove foods and medications isolating side effects or allergies. Last week, I attended the HIMSS conference, the largest healthcare conference in the country, with attendees from around the world. One executive stated, "I just returned from Finland where they have an effective health system, because people live healthy, and the doctors appropriately tell their patients NO when seeking a simple, quick fix of a drug that is not needed."
Reasons for the mainstream SOP?
I think there are always multiple reasons for issues within healthcare. The symptom=prescription issue can be: Doctors are processing patients through with 'factory-care', Physicians receiving kickbacks from pharmaceutical companies; The lack of proper clinical training; Protocols blindly being followed without individual evaluation (e.g. Vanderbilt University study on Plavix standard for all Cardiac Cath Patients); as well as the alliance of public policy and pharma, direct consumer marketing without proper education.
A healthcare executive summarized the situation well last week when stating to me, "I ultimately make the decision for my own care, with the advice of the physician. It is the doctor's role to diagnosis, and then we discuss all options, along with a plan of care, coordinated with speaking with all other involved physicians." It is important for consumers to understand the need to champion their own care working with physicians, determining what options should be used before medications (diet and some of the old fashioned home remedies still hold true), addressing underlying issues versus only symptoms, and removing or changing medications to eliminate side effects when there are alternatives. Questions to have answered:
An example of direct consumer marketing lacking in education: In 2016, there was broad publication when the company Mylan raised the prices of the Epipen after State Law was passed to stock it in every school. Many individuals and groups were upset because there is not a generic offering. With proper information, the public would be educated that Epipen is the patented delivery system, not the drug epinephrine. The generic already existed in the form of a $15-$18 sterile needle. It is also necessary to establish where and when is it appropriate to stock epinephrine, not specifically the Epipen.
Why are you prescribing this medication, what is it specifically doing in my system?
What are non-medication alternatives, what are other medication alternatives?
How long should I take this, what is the outcome? How does it interact with my other medications?
What should be monitored for an outcome, side effects?
Recently, the April 2007 story of Chief Mike Day, Navy SEAL, has been recirculated. The incident involved Day being shot point blank, 27 times (11 in his vest and 16 times into his body), within a 12 x 12-foot room, the gun fight occurring within seconds at a range of ten feet. After his rifle was shot out of his hands, he grabbed his pistol, remaining in the fight, taking out the four insurgents, and then becoming stunned being hit by a grenade fragment. Upon regaining awareness, he immediately inquired if the room was clear, and then walked himself to the evacuation helicopter. In one of his interviews, he stated, “I just went to work, it was muscle memory, I just did what I was trained to do.” “… into a gun fight, I feel more comfortable in that situation, I feel more comfortable, I don’t think, I don’t have to think in that situation, I just react.”
Day’s statements exemplify an important component that has been lost in healthcare training - that of muscle, or specifically, movement memory. Clinicians are supposed to be trained in school regarding the need and proper technique for handwashing. More importantly, clinicians used to have extensive clinical time working in patient areas developing the movement memory for proper hand washing, and automatically keeping in mind what is clean vs. dirty, where established sterile fields are located with maintaining of sterile gloved hands. The training was extensive and repetitive, for clinicians to automatically move appropriately in fast paced, life threatening situations - to not have to think and just act. One common, simple example is the insertion of IVs for fluid administration or needles for drawing blood. The needle or IV cannula (the needle with covered sheath inserted into the vein) is sterile, with clinicians wearing nonsterile gloves. The skin is typically wiped with alcohol to clean, and then all too often clinicians press nonsterile gloved fingers on the cleaned skin to feel for the vein; thus, contaminating the cleaned surface of the patient’s skin where insertion directly into their vein will occur. Even though the nurse/doctor is wearing clean gloves, they are not sterile, and worn to protect the clinician. With repetitive movement training, clinicians would press to find the vein before properly cleaning the skin, and clean their gloved fingers at the same time as the patient’s skin.
Two frequent complaints often heard from patients, "They dug around in my arm and could not find the vein, it was so painful." "They poked me five times because they did not know what they were doing." Blood draws and starting IVs is a skill, just like shooting at a target or in high stress a gun fight, that requires proper training of technique, and more importantly, repetitive practice - especially with the understanding when someone's life depends upon it. Additionally, the conditioned good technique should be second nature to purge ALL air from needles and tubing, including from the side ports of IV tubing, to prevent the potentially fatal embolus as a hospital acquired condition (HAC).
With the great reduction of hands on clinical time in schools (with replacement of online theory, population/global health, writing, and shadowing nurses), this movement memory training has been lost, with the shift of cost to hospitals for training, buying expensive monitoring equipment, or addressing the subsequent HAIs/HACs. Bringing the ingrained, repetitive movement training back to school training would instill within clinicians and CNA/PCT caregivers the instinctual, reactionary awareness of dirty versus clean or sterile, and proper IV/needle insertion, while delivering care; whether normal daily care or imminent life versus death situations – because they just do what they are trained to do without having to stop and think through quality actions.
Upon reading the article "Must have bachelor's degree: Hospitals' new requirement for nurses" concerning a report published by The Wall Street Journal, I wanted to provide perspective from experts with first-hand experience in the industry addressing points within and not included in the Wall Street Journal report. [read more]
“I spoke to more than 40 people for the story and heard many of the points you raise, unfortunately I could not include every nuance in a 700-word story. All the best, Anna” WSJ journalist
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