Business as Usual
by Frank H. Boehm M. D.
(Healing Words, May 27, 2006)

In 1999, the prestigious Institute of Medicine published a report entitled To Err is Human, which claimed that up to 98,000 deaths occur each year in United States hospitals due to errors made by health care providers. This astonishing report pressured the health care industry to make changes that would correct the problem of errors made in the care of hospitalized patients. Now, seven years later we learn that the number of deaths that occur each year in American hospitals have actually increased, perhaps even doubled! It appears we are back to business as usual. What is going on here?

It is not that the health care industry has not tried to correct the problem of medical errors; rather it has not been focused on the real issues causing medical errors. This assessment comes from two distinguished experts on the subject of medical errors writing recently in two prestigious medical journals.

In The New England Journal of Medicine, George J. Annas writes that he believes the law should recognize patient safety as an inherent right. He believes it is the responsibility and duty of all hospitals to make sure that this right is protected and hospital responsibility can become a major motivator for developing systems in hospitals to reduce medical errors. This, Annas states, is contrary to the popular premise that it is lack of tort reform to reduce liability that is the real barrier to putting into place hospital safety programs. Annas goes on to say that “Hospitals that do not take specific actions to improve safety should be viewed as negligent and be subject to malpractice lawsuits when a violation of the right to safety results in injury”.

Annas also believes that all hospitals in America should put into place a system of reporting all errors, as well as what he calls near misses for quality control, which is to “make sure patients are told when their injuries were caused by errors”. He does not believe that universal reporting and being open and honest with patients will drive up malpractice claims since no study has yet shown that reporting medical errors has increased medical malpractice rates.

Vanderbilt is one of the few hospitals in this country that has made a patient’s right of safety a top priority. We are working with system management groups in an attempt to change the culture of doing business with our patients. Initiating a computerized mechanism to place medical orders in a patient’s chart (which has resulted in a significant reduction in medication errors), and hiring consultants from the highly effective safety conscious airline industry to work among doctors and nurses to put into place processes that lead to reductions in communication and system errors, are two examples of how Vanderbilt has taken seriously the right of a patient to safety.

Annas’s bottom line is that with a national adoption of a patient’s right to safety, hospitals will be more likely to take measures to meet a goal of safety since failure to do so would result in increased liability to the hospital.

Dr. Louis Weinstein, writing in The American Journal of Obstetrics and Gynecology, also addresses the issue of preventing medical errors. He claims that, “The emphasis of most physicians and medical professional societies has been on seeking tort reform with the imposition of non-economic damage caps and contingency fee limits”. He believes the medical community needs to spend more effort on preventing errors than attempting to reduce liability for medical errors. He has a point.

Medical errors that lead to patient harm are most often system errors and, therefore, with determination and a will to change, amenable to repair. Weinstein believes that tort reform does not address medical errors that are preventable and also believes we should remove the privilege of non-disclosure of peer review systems in hospitals so as to regain public trust.

Without an open dialogue with our patients, as well as implementation of many other processes to effect patient safety, we are doing nothing to put into place a system that will result in a reduction of hospital errors (while increasing lack of trust in the medical profession). The recommendations by these two experts on the subject may be controversial but at least they are addressing the untenable situation of an increasing rather than decreasing number of medical errors that lead to patient death. We need to pay more attention to what they say.

(Dr. Frank H. Boehm is Professor of Obstetrics and Gynecology at Vanderbilt Medical Center. His e-mail is frank.boehm@vanderbilt.edu.)

Trust
(Healing Words Column)
by Frank H. Boehm, MD

Trust is the glue that binds one human to another. It is the foundation which brings each of us peace and comfort, tranquillity and calm. Without trust we are shipwrecked on a sea of confusion, insecurity, fear, and pain.

Trust is not easily achieved and often takes time to be affixed to the soul as is the case with the building of friendship or love. Other times trust comes quickly as when we strap ourselves into an airplane seat awaiting take off and a trip high into the sky. Yet regardless of how long it takes us to achieve a sense of trust, it is this human feeling that allows us to feel safe and protected.

In the dispensing of medical care, trust is paramount. Patients who trust their doctor to help them through the rigors of maintaining or attaining good health are rewarded by a sense of peace. Without it patients are often lost, confused and afraid. It is this trust between patient and physician that is critical to an effective relationship and vital to achieving a positive result.

I have often marveled at the fact that many of my patients, once feeling this sense of trust, will allow me to make critical decisions for them in times of their greatest need. I am honored by this trust, yet I know that it did not happen each time just because I wore a white coat, carried a stethoscope and called myself “Doctor”.

When strapping yourself into an airplane seat, that sense of trust in nameless, unknown pilots comes quickly. Aware that you are about to be lifted 35,000 feet into the air and flown to a destination hundreds or thousands of miles away, you none the less feel an element of trust. Part of that feeling comes from the fact that you know it took an incredible amount of time, training and experience to be given that job to take you to your destination.

Another part comes as well from the understanding that these unknown men and women sitting in the cockpit are just as concerned in their safety as they are in yours. Their well being is tied into your well being. If you go down, so do they. You are comforted by that fact and are therefore infused with an almost instantaneous feeling of trust.

It is this same level of trust that is so critical to a relationship between patient and doctor. Yet in most instances that feeling takes more time to develop. Knowing that your doctor has passed the rigors of years of medical training, has been certified by a number of prestigious organizations, State and National certifying bodies and has had years of medical experience, there still is that understanding that if some aspect of your care results in a less than optimal outcome, your physician does not “go down with you”.

Because of this, an additional aspect of the relationship between patient and physician needs to be added. That additional layer is a feeling of closeness which comes about in a variety of ways. Casual conversations during office visits, sharing of personal life experiences or merely discussing important issues of the day are but a few of the ways doctors and patients form a close trusting relationship. The more our patients begin to know who we are as individuals and begin to understand some of our fundamental beliefs, the more our patients will feel a sense of closeness and caring.

The more each knows about the other the better the physician is in taking care of his or her patient and the more the patients feels trust in the physician.

In an ever increasing medical technological environment in which human touch is easily replaced by machines and drugs, it is imperative for doctors to achieve and maintain a patient's trust through expert care dosed along the way with personal interactions.

In a world ,where the house calling family doctor no longer exists, it is critical for doctors to strive for that feeling of trust that patients so eagerly yearn.

I believe instilling trust in what we say and do, along with providing excellent medical care, is our goal as doctors.

Dr. Frank H. Boehm is Professor of Obstetrics and Gynecology at Vanderbilt Medical Center.

He can be reached at frank.boehm@vanderbilt.edu.

HIV Testing
(Healing Words Column)
by Frank H. Boehm, MD

It was not long ago that Obstetricians across the United States were debating whether to routinely screen all pregnant women for HIV, the virus that causes AIDS. Thankfully, despite problems complicated by privacy, political and social issues, those in favor of offering testing to all pregnant patients won the debate.

It was discovered in the 1990s that antiviral treatment during pregnancy along with a six- week treatment of the newborn resulted in a significant reduction of babies becoming infected by their mother. Consequently, doctors were convinced that by being able to make an early diagnosis in a woman’s pregnancy, they had a wonderful opportunity to treat those HIV positive patients throughout pregnancy and thereby reduce the overall percentage of infected babies from a high of 25% to a low of only 1%. It worked!

In 1990, approximately 2000 HIV infected babies were born in this country because of transmission of virus from mother to baby. With early diagnosis and treatment that number today has reached an all-time low of 200 a year. Locally, the news is equally good. In 1997, Vanderbilt’s Department of Obstetrics and Gynecology, along with Infectious Disease specialists working at the Comprehensive Care Center in Nashville, began a clinic to care for those pregnant women who were found to be HIV positive. This cooperative program has resulted in the delivery of approximately 150 treated mothers during the past ten years whose babies have all been found to be free of the HIV virus. Today, with early diagnosis and aggressive treatment during pregnancy, a woman who is HIV positive can be encouraged that her baby will have a very small chance of becoming infected.

A new debate on HIV testing is now underway in this country and the stakes are equally as high. It is estimated that approximately one million Americans are infected with the virus that causes AIDS. A huge problem is that of this one million, close to 250,000 are not aware that they are infected. With approximately 40,000 new HIV infections occurring each year, the problem of undiagnosed Americans will continue to grow. The current debate concerns whether routine HIV testing should be offered to all Americans.

During the early 1980s, government recommendations included HIV screening only in cities with large populations where HIV positive rates where considered to be high and among high-risk groups such as gay men and IV drug addicts. With the advent of effective medications to treat AIDS, many physicians have urged for a change of these recommendations. Two published studies have now given support to the premise that all Americans should be tested.

One of these two studies revealed that routine one time testing could reduce new HIV infections each year by 20% and that those newly diagnosed patients could have their life expectancy extended. The other study noted that routine testing for HIV every three to five years would be cost effective.

Currently, government guidelines recommend that routine HIV testing be performed in high- risk populations where infection rates are found to be one in one hundred or higher. However, new data now also reveals that even in populations where the infection rates are one in two thousand (the rate in the general population), each relatively healthy year gained by newly diagnosed HIV patients would nonetheless cost less than $50,000, an amount considered by experts to be cost effective for society. Dr. Lawrence Deyton, chief of public health of the Department of Veterans Affair stated that, “The cost benefit to individuals and society is worth widespread screening”.

It now appears that target screening for HIV in high risk populations is no longer working and that routine screening on a periodic basis is what doctors should be offering patients. Those individuals who are in a monogamous relationship and who are not exposed to illicit drug use could be tested once and if found to be negative would not need repeat testing. Those individuals, however, who are considered at any increased risk, should undergo repeated screening.

There are some negative effects of universal screening. There is one false positive result for every 200,000 individuals in the general population screened and those individuals will need counseling and reassurance. Budgets for some clinics will be pushed to the limit and fear of HIV screening may lead some patients who are at increased risk for HIV to avoid seeking medical attention for other conditions. Therefore, screening should be routinely offered but not mandatory.

Despite these problems, many experts now believe that a wider net should be thrown out in our society in order to pick up the over a quarter of a million HIV infected individuals who have no knowledge of their infection. These newly diagnosed patients could begin earlier treatment, extend their life expectancy and at the same time be able to practice preventive sexual activity with their partners. It is time for the general population to begin a practice that has been proven effective in the general pregnant population. Too much is at stake not to do so.

Dr. Frank H. Boehm is Professor of Obstetrics and Gynecology at Vanderbilt Medical Center.

He can be reached at frank.boehm@vanderbilt.edu.

Obesity and Health Care Costs
(Healing Words Column)
by Frank H. Boehm, MD

Recently I viewed a video of a Cesarean Section performed on a woman who weighed 652 pounds! (Her baby weighed a normal 7 pounds). While I have had patients whose weight was in the 400 pound range, the video was alarming as well as troubling. Unfortunately, Americans are getting larger and larger each decade. It has been reported that the incidence of obesity in America has increased dramatically over the past 20 years and that one out of every three women in this country is now considered obese.

Keep in mind that there is a difference between being overweight and obese. The World Health Organization defines normal weight as a body mass index (BMI) of 18.5-24.9; overweight 25-29.9; and obesity, greater than 30. To calculate your BMI, which uses height in inches and weight in pounds to determine results, just go to Google.com and type in BMI and use their calculator.

The woman, in the video, undergoing a Cesarean Section had a BMI significantly over 40, a figure considered in the extreme or morbid range and was at an alarming increased risk for serious medical complications. Obesity in women of childbearing ages is related to an increase in miscarriages, stillborns, premature births, fetal spina- bifida, overly large babies, diabetes mellitus, hypertension and toxemia of pregnancy. In addition, the cesarean delivery rate increases as a woman’s BMI increases; reaching almost 50% in women whose BMI is 35-40. Postoperative complications are also higher in obese women and include a higher incidence of excessive blood loss, longer operative time and an increase of wound infections. Obesity is not just a problem for pregnant women.

Obesity for the general population is associated with an increase in death rates and in one study, an estimated 112,000 individuals die annually of obesity associated causes. Besides an increased incidence of deaths, obesity has been associated with an increase in type 2 diabetes, hypertension, heart disease, gallbladder disease, osteoarthritis and a number of cancers, including breast, uterine and colon. In other words, obesity kills as well as causes serious illness for a large population of Americans.

However, in addition to an increase in death and disease, obesity is costing Americans a huge amount of money spent on obesity related medical problems. In order to take care of obese patients, hospitals have to build special beds, chairs, toilets and operating beds, simply to able to admit extremely obese patients and perform surgical procedures in a safe manner. The added cost to care for hospitalized obese patients is a problem for hospitals throughout America.

Clearly, this increase in obesity is part of the reason the average cost for a family health insurance policy has now reached almost $11,000 a year, according to a recent survey conducted by the Kaiser Family Foundation. Growth in medical insurance costs is now higher than growth of work wages as well as inflation. We cannot continue to add higher costs to what individuals and families must pay each year for health care insurance without continuing to add to the already swollen number of medically uninsured Americans.

The Kaiser survey noted that only 60% of employers offered health care coverage, down from 69% just five years ago. Most of the reduction comes from small companies, which cannot afford these kinds of costs for their employees. Many large companies with over 200 employees, who do offer health care insurance and who pay an average of 74% of an employee’s plan, are attempting to reduce their overall costs by giving incentives to reduce high risk behavior effecting general health, such as smoking, lack of exercise and over eating. Employees who lose weight and thereby avoid certain obesity related illnesses save money for the employer. All this, however, will not be enough.

Obese Americans need to wake up and understand that they are killing themselves. The medical community can only do so much. This is not so much about being somewhat overweight but rather about being in the obese category as determined by one’s BMI. We need to find a way to help the one third of our population who are obese, tackle their weight problems. It will not be easy, but it has to be done.

Dr. Frank H. Boehm is Professor of Obstetrics and Gynecology at Vanderbilt Medical Center.

He can be reached at frank.boehm@vanderbilt.edu.

The Genetic Side of Pain
(Healing Words Column)
by Frank H. Boehm, MD

Over the years I have witnessed thousands of women give birth and I have found that people have many different reactions to pain, and that pain is an extremely complex process.

For a long time I have believed that a person’s reaction to pain would someday be proven to be heavily influenced by genetic factors, and that we will learn that there are genes which express our ability to handle pain. The identification of these genes will help us understand why some patients have an extremely low threshold for pain while others a very high one. Recently there has been information that gives support to this belief.

Reports of a small number of people throughout the world who do not feel any pain, give convincing proof that genes play a major role in the perception of pain. A condition called congenital insensitivity to pain with anhidrosis (CIPA) is a rare genetic disorder inherited from both parents that makes an individual unable to feel pain or adapt to extreme external temperatures. CIPA disrupts the development of nerve fibers which transmit sensations of pain, heat and cold to the brain. It renders the body incapable of a critically important protective alarm system.

While you may think that the inability to feel pain is a good thing, let me tell you, it is not. Individuals who are unable to feel any pain are in extreme danger of serious harm. Imagine if your appendix ruptured and you could not feel pain and therefore did not seek medical attention. What would happen if you fell and broke a bone or touched a hot stove and could not react with a quick response of moving your hand? Children afflicted with CIPA have to be continuously watched at play and adults have to carefully monitor their bodies for unfelt injuries.

Much of human behavior is on a continuum with extremes on either side of average. Sexual preference, intelligence, athletic ability and temperament are a few examples. The fact that a condition exists which renders an individual incapable of feeling pain caused by a genetic disorder, explains why there are some individuals, at the other end of the spectrum, who are very sensitive and incapable of handling even the smallest amount of pain. The majority of us fall somewhere in the middle of this wide continuum of pain perception.

Because of this genetic connection to pain we should be more tolerant of those who seem to be the most intolerant of handling pain. They are most likely not weaklings or complainers, but rather genetically endowed with an extremely efficient nerve response system, the very opposite of those inflicted with CIPA.

The medical profession should teach its practitioners that pain is not only subjectively perceived and expressed; it is also affected by a more objective modality of genetic expression. In other words, a patient who states that her headache or labor pain is a ten out of ten should be treated as if that pain is truly severe. It is also important, when confronting a patient who claims their pain to be minimum, to still consider more serious pathology if other clinical factors suggest it.

All this is not to suggest that pain is only expressed through genetic factors. Consider the impact of prayer on pain, or that of the placebo effect. Recently it was reported that patients with severe migraine headaches responded positively to acupuncture when it was properly performed, as well as when it was not. In the May 2005 issue of the Journal of the American Medical Association, it was reported that 51% of patients had significant reduction of the pain caused by migraine headaches when they underwent properly administered acupuncture, while 53% of similar patients also noted reduction of pain even when the acupuncture needles were placed at non-acupuncture points.

Clearly, pain is a complicated process and one with which the medical profession constantly struggles. We have improved our evaluation of pain and are making headway in treating it as well. It is still important, however, for both doctor and patient to understand that the management of pain remains one of the most significant ingredients of good medical care.

Dr. Frank H. Boehm is Professor of Obstetrics and Gynecology at Vanderbilt Medical Center.

He can be reached at frank.boehm@vanderbilt.edu.