quinta-feira, 23 de abril de 2015

Algumas mensagens de hospitalistas norte-americanos para mim, ao longo destes anos…

PARTE 1 - Leia aqui


Por: Alpesh Amin em 13/11/2010.

It is wonderful to see Hospital Medicine's growth not only in the United States, but also in other countries such as Brazil. The field of Hospital Medicine has come a long way over the past 15 years. Many hospitals no longer can do without hospitalists and are asking hospitalists to take on important leadership roles within the institution. Hospitalist, as inpatient physician specialists, have mostly been from an Internal Medicine background, but the field is expanding to other specialty areas. At the University of California, Irvine (UCI) we have hospitalists trained in Internal Medicine, Pediatrics, Family Medicine, Critical Care, Geriatrics, Palliative Care, Infectious Disease, Neurology and Nephrology. All our hospitalists work together as one programmatic unit and view each other as partners. The connection is our interest in inpatient care, quality and patient safety, inpatient curriculum development and education, and systems based practice. We also have hospitalists working in Informatics, Medical Education, Safety and Quality, and Administration. Our hospitalists lead areas such as anticoagulation, perioperative care and are very involved in practice improvements such as infection control and medication safety. As we continue to evolve as a field of Hospital Medicine our role in establishing and leading multidisciplinary teams to achieve quality of care and outcomes will be key and partnering with case management, social worker, pharmacy and nursing will be important to achieve our goals. Ultimately, we will be an integral part of the institutional infrastructure to help our hospitals partner with community practices and third party insurances to achieve the optimal health care delivery model. I am excited about the future of Hospital Medicine.

Por: Esteban Gandara em 23/10/2010.

The question is how you manage change. And that depends on your institution. Lets be honest, it takes years to accept evidence based care, so let alone trying to change the way institutions run, it is much more difficult. My take would be to show your hospital board that you are bringing money to the table. Your board wants you to cover the RRT, do it, and show that your care would have prevented that event. Hospital administrations only understand one thing and that is money. The hospitalist must prove that it can reduce cost of care (by providing evidence based high quality care). If you have outside doctors, they tend to have their patients hospitalized for more days. Measure and show to board you would have discharge the patient early, reduce the numbers of X-rays, or the days of IV antibiotics. Work with the ER to reduce admissions. Contrary to the comments of the Happy Hospitalist, I would capitalize those moments with surgeons and nurses. Trust me any surgeon would prefer to be in the OR, not taking care of the patient with fever or SOB. But remember always measure the times you receive calls and times you were involved. Finally we are not owners of the patients, we are part of a team of providers. We should remember that sometimes doctors outside the hospital are highly involved with the care of their patients, and multiple times I have seen hospitalists take care of patients without consulting or even taking into account the input of their primary provider.

Por: Moises Auron, hospitalist at the Cleveland Clinic em 20/10/2010.

The Hospitalist is a specialist that has a focused practice in the inpatient management and acute care. The advantage of this sub-specialty of Internal Medicine and Pediatrics is that in addition to a more focused approach, the Hospitalists drive quality improvement initiatives, as well as focus on improvement of patients' outcomes. The primary care physicians can focus entirely on preventive medicine and urgent care visits without splitting their time between their office and the hospital. In addition, the patient care improves as the hospitalist is more focused on certain benchmarks that the primary care provider is not accustomed to use - such as VTE prophylaxis, inpatient use of appropriate IV antibiotics, anticoagulation, management of delirium, acute decompensated heart failure, etc. The issue in Latin America (I'm originally from Mexico city) is the fear of losing patient's ownership - this won't occur with Hospital Medicine. The hospitalist just work in the hospital and has no outpatient practice - so no risk for "stealing" the patients. In addition, the patient receives much better care as inpatient, not only because of the hospitalists' expertise, but because the hospitalist do not need to fragment their time between seeing both outpatient and inpatient visits. The fear of losing continuity of care is overcome by an enhanced communication between primary care doctors and hospitalists, which permits a better transition of care between inpatient and outpatient. In addition, it is important to ascertain that the hospitalist movement has achieved so incredible success, that the American Board of Internal Medicine is recognizing it by means of providing recertification through a Focused Practice in Hospital Medicine examination. The academic development of hospitalists has increased exponentially in the past 10 years, and is continuing to grow; hospitalists are the ones who are driving all the inpatient quality of care and patient outcomes improvement projects in the USA. There is always fear to change, and I understand the Latin point of view, especially from elderly physicians, however in the US, there are a substantial amount of senior doctors who are switching their practices from outpatient to entirely inpatient, and allow other people to see their patients as continuity primary care providers, while they just see them in the hospital. Interstingly, they have achieved a significant professional and personal satisfaction. Just my 2 cents.

Por: Efren Manjarrez, HM, University of Miami em 11/10/2010.

The original paper by Bob Wachter in 1996, New England Journal Sounding Board, projected that for the purpose of cost and efficiency, hospitalists would excel. He said that it is impossible for office-based physicians to be able to respond to the rapid pace of inpatient medicine while running a busy office. Also, since office based physicians would begin to drop off in the hospital, then the clinical skills of the office based physician trying to keep up with hospital medicine would not be successful. For an office based physician to manage the care of inpatients, then have the hospitalist “follow the orders” of the outpatient physician would not be efficient. Also, this would be like the blind trying to lead the sighted. This sounds like office based physicians being concerned about losing their patients, which should not happen in the hospitalist model. The literature supports quality, patient satisfaction, and improve costs of the hospitalist model. The literature is strong in this area, and the literature, therefore should drive the argument based on evidence, not unfounded political concerns of office based physicians. The Davis paper also shows that by giving up hospital care to hospitalists, then outpatient physicians actually make more money. Inpatient care directed by an office based physician is now 15 years outdated… Hospitalists are professionals and specialists. Taking orders from outpatient physicians would be like hospitalists trying to tell primary care physicians how to run their offices, when we have no clue how to do that!!

Por: David Klocke, Chair, Division HM, Mayo Clinic em 04/10/2010.

Dedicated full time hospitalists improve the care of hospitalized patients. This has been clearly demonstrated in the United states. Hospital administrators need to advocate for hospitalists or equally dedicated physicians who work a large proportion of their time in direct patient care in the hospital. Administrators must also measure quality indicators, mortality, length of stay, readmissions, infection rates, cost per case and other metrics and set minimum standards for physicians who practice in their hospital whether they are traditional internists or hospitalists. The standards should be the same for all. Perverse financial incentives will unfortunately promote care processes that are not necessarily in the best interest of the patients. For clinic physicians to let go of their inpatient practice to hospitalists assumes there is adequate other work to do in the outpatient setting for which they can earn a similar standard of living. 

Por: Jack Percelay, Pediatric Board Member for the SHM em 02/10/2010.

Try the argument that there can only be one captain of the ship. If the primary care doctor wants to manage the patient him or herself, that is fine, but you as hospitalists would not get involved because there is too much of a potential for a mix up or confusion (The English proverb is too many cooks in the kitchen). Ultimately, you will probably have to prove yourselves locally by demonstrating superior service and outcomes with smaller numbers of patients. Once you have a record of success, including a record of cooperation and referral back to the primary care physician with excellent communication, these primary care physicians will recommend the use of a hospitalist to their colleagues. You may want to start out by calling and updating the primary care doctor regularly (perhaps daily, perhaps faxing notes) just to keep that doctor in the loop and reassure the patients that you are all on the same team. But you can't be a "super resident". That is not satisfying for you, and ultimately is not good for patient care because there are bound to be miscommunications. Set up a reasonable plan together with the primary care physician on admission, stick to it, and update the primary care physician with any deviations from the plan. Above all, be patient. Don't try to force referrals. Let them come to you. 

Por: the Happy Hospitalist Hospital Medicine Blog.

There are good programs and there are bad programs. The good programs have administrators that understand the exceptional value hospitalists bring to the table. Great programs do not run their board certified internal medicine physicians into the ground. If they do, and the physician chooses to stay and work in that environment, that's up to them. I would never put up with such a program. 

Por: the Happy Hospitalist Hospital Medicine Blog.

Hospitalists should take care of patients just like everyone else. We don't do skut work, the essence of being defined as a resident. I manage patient care issues just like physicians who round and head back to their clinics. When our program first started, we were being asked by surgeons to read chest xrays for their line placement after they left the hospital. We put an end to that real soon. It just doesn't happen anymore. We used to get asked to declare patient deaths because we were in house. We put an end to that real quick. If I get called on blood work on a patient that was ordered by another physician or that is being managed by another physician but I'm just the easiest to call, I will tell the nurse to call the other doctor, even If I know the answer to their question. We are not the nurse's doctor of convenience. Nor am I paid by other doctors to field their calls for them. That's what they pay an NP or PA to do for them. 

quarta-feira, 22 de abril de 2015

Choosing Wisely International

Será com muita satisfação que participarei, junto com meu amigo Luis Claudio, do Blog Medicina Baseada em Evidências, de evento fechado da Choosing Wisely International:

2nd International Roundtable on Choosing Wisely, taking place in London, UK, on Thursday, May 28 and Friday, May 29, 2015.

Luis representará a Sociedade Brasileira de Cardiologia, enquanto representarei a Sociedade Brasileira de Medicina de Família e Comunidade, a quem agradeço fortemente pela oportunidade e confiança. SBC e SBMFC serão pioneiras ao inserir o Brasil na Choosing Wisely International (bastidores podem ser conhecidos aqui). Já estamos em tratativas com outras especialidades.

Os propósitos principais do evento, que reunirá lideranças de 16 países, são:

1. Compartilhar experiências sobre iniciativas “choosing wisely” nos diversos países;

2. Compartilhar estratégias de sucesso e desafios para implantação da Choosing Wisely, através dos cases norte-americano e canadense;

3. Discutir formas de melhor avaliar efeitos da campanha e, se possível, padronizar isto entre os países envolvidos.

Representantes da Organisation for Economic Co-operation and Development (OECD) and The Commonwealth Fund estão também envolvidos na iniciativa.

Abaixo a programação preliminar do evento:
2nd International Roundtable on Choosing Wisely
Royal College of Anaesthetists, Second Floor Gallery
35 Red Lion Square, London
9:00 – 9:15am
Welcome and Framing of the Meeting
Wendy Levinson
9:15 – 10:00am
Participants Identify Major Challenge
Description: Each person will introduce themselves and one representative from each country will name the main challenge they would like help with.
10:00 – 10:30am
Underlying Principles of Choosing Wisely and Application to Recommendations Development and Implementation
Description: Identify cultural shifts in society and business that are in play with Choosing Wisely including Self-Determination Theory and Complexity Theory.
Daniel Wolfson
10:30 – 10:50am
10:50 – 11:20am
Challenges and Successes in Implementation in Canada and US
Description: Using a structured format, identify strategies that have been employed and the challenges.
Wendy Levinson
Tai Huynh
11:20am – noon
Part 1 of Open Space
Description: Small groups will have the opportunity to work on topics of specific interest. The question “what do you want help on during this meeting” might form the basis of topics.
Daniel Wolfson
Noon – 12:45pm
12:45 – 2:00pm
Part 2 of Open Space
Description: Each group develops strategies and immediate actions steps. Each group reports out.
Daniel Wolfson
2:00 – 2:30pm
The Top Ten List
Description: We will revisit the list of top ten tests/treatments/procedures from last year and revise based on previous and current work. This list will form the basis for a later discussion with OECD.
Wendy Levinson
2:30 – 2:45pm
2:45 – 3:30pm
Framing Evaluation and Measurement
Description: Review of key evaluation efforts to date and challenges and barriers in evaluation.
Sacha Bhatia
3:30 – 4:30pm
OECD and Measurement of Overuse
Description: Explore cross-country comparisons of a limited set of recommendations.
Niek Klazinga
4:30 – 7:00pm
Social Dinner
Royal College of Anaesthetists, Council Chamber
35 Red Lion Square, London
Royal College of Anaesthetists, Second Floor Gallery
35 Red Lion Square, London
9:00 – 9:30
Summary of Prior Day’s Discussion
9:30 – 10:30am
Evaluation and Measurement – What is Next?
Description: What’s currently happening in other countries? Is there agreement on a framework to measure Choosing Wisely impact? How do we want to collaborate?
Small groups
10:30 – 10:45am
10:45 – 11:30am
Evaluation and MeasurementContinued
Large group
11:30am – 12:30pm
Patient/Public Engagement
Description: Discussion of strategies for patient/public engagement. What’s working and what are challenges?
12:30 – 1:30pm
1:30 – 3:00pm
Working Together Between Annual Meetings
Description: Discuss how this group wants to work together (i.e., small groups); how to organize the work and how we support each other.
Sam Shortt
3:00 – 4:00pm
Conclusion and Final Thoughts
Description: Identification of group goals and who will lead components.
Wendy Levinson

Suggested Readings
  1. Academy of Royal Colleges. Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care. 2014 Nov.
  2. Coronini-Cronberg S, Bixby H, Laverty AA, Wachter RM, Millett C. English National Health Service's Savings Plan May Have Helped Reduce The Use Of Three 'Low-Value' Procedures. Health Aff (Millwood). 2015 Mar 1;34(3):381-9.
  3. Gliwa C, Pearson SD. Evidentiary rationales for the Choosing Wisely Top 5 lists. JAMA. 2014 Apr 9;311(14):1443-4.
  4. Gupta S, Detsky AS. Development of Choosing Wisely Recommendations for an Inpatient Internal Medicine Service. JAMA Intern Med. 2015 Feb 23.
  5. Kerr EA, Chen J, Sussman JB, Klamerus ML, Nallamothu BK. Stress Testing Before Low-Risk Surgery: So Many Recommendations, So Little Overuse. JAMA Intern Med. 2015 Feb 9.
  6. Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA; Choosing Wisely International Working Group. 'Choosing Wisely': a growing international campaign. BMJ Qual Saf. 2015 Feb;24(2):167-74.
  7. Mason DJ. Choosing wisely: changing clinicians, patients, or policies? JAMA. 2015 Feb 17;313(7):657-8.
  8. Selby K, Gaspoz JM, Rodondi N, Neuner-Jehle S, Perrier A, Zeller A, Cornuz J. Creating a List of Low-Value Health Care Activities in Swiss Primary Care. JAMA Intern Med. 2015 Feb 23.
  9. Strech D, Follmann M, Klemperer D, Lelgemann M, Ollenschläger G, Raspe H, Nothacker M. When Choosing Wisely meets clinical practice guidelines. Z Evid Fortbild Qual Gesundhwes. 2014;108(10):601-3.

domingo, 19 de abril de 2015

Hospital dispensava idosos e internava jovens

Um esquema de corrupção montado em um hospital de São Paulo desviava recursos do SUS (Sistema Único de Saúde) dispensando a internação de pacientes idosos ou com doenças graves, aceitando no lugar deles os mais jovens e saudáveis. O objetivo era ocupar os leitos por apenas um dia e atingir metas com o maior número de internações.

No hospital Santa Marcelina, no Itaim Paulista, zona leste da capital, não atender idosos foi uma determinação do responsável pela contratação de vários profissionais, o também médico José Carlos Dias Pereira. As ordens eram dadas via WhatsApp e, nas mensagens, os médicos eram comunicados sobre quantas internações cada um deveria fazer e quem poderia ser internado.

Em uma mensagem de celular, ele destacou o que era preciso fazer: instruiu que seriam doze internações por dia, seis para cada médico do Fluxo Verde. A cor determina a gravidade do estado do paciente e o verde significa risco zero.

Em outra mensagem, Dias Pereira alertou para o perfil das internações: “Os pacientes devem ser: jovens, hígidos, com diagnóstico simples e precisos, para podermos dar alta com segurança! Evitem pacientes idosos, com ICC, pneumonia e múltiplas comorbidades”, escreveu.

Assim, os pacientes do chamado Fluxo Verde não chegavam nem a passar por exames, como apurou com exclusividade o Jornal da Band.

O hospital Santa Marcelina Itaim recebe verbas do SUS através da Secretaria Estadual de Saúde. Os médicos que trabalham no pronto-socorro e no atendimento de alguns andares são terceirizados pela empresa Dias e Dias medical, de propriedade do médico e gestor de saúde pública José Carlos Dias Pereira.

O Conselho Regional de Medicina de São Paulo (CRM-SP) abriu sindicância para investigar a denúncia e averiguar se houve participação do hospital no esquema. O hospital confirma que existem metas a serem cumpridas junto à Secretaria Estadual de Saúde, mas nega ter orientado médicos a selecionar internações.

O caso foi parar também na Promotoria Pública, que promete agir com a ajuda do Gaeco (Grupo de Atuação Especial de Combate ao Crime Organizado).

Em nota, a Secretaria de Saúde pediu a apuração imediata dos fatos e determinou o rompimento do contrato do hospital com a Dias & Dias Medical, além de ordenar a contratação de outra empresa, sem a interrupção do atendimento aos pacientes.

Vale a pena ver na fonte e assistir o vídeo: http://noticias.band.uol.com.br/cidades/noticia/100000724132/hospital-recusava-idosos-e-internava-jovens-saudaveis-para-bater-meta.html

segunda-feira, 13 de abril de 2015

We don’t offer recruiting services or employ your doctors.

Para entender melhor um posicionamento histórico meu e que culmina na defesa intransigente de protagonismo (com critérios meritocráticos e transparentes) para quem é do hospital e a ele, e pouca coisa mais, dedica-se.

Não representa dizer que o oposto é necessariamente ruim.
Mas de reconhecer alguns conflitos de interesses resultantes, que podem nos fazer olhar mais para um lado do que o outro.

Talvez por isso, John Nelson, um pioneiro em Medicina Hospitalar,

tem muito assertivamente em seu site: 
We don’t offer recruiting services or employ your doctors.
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