Nighttime

No matter who you are there are two health care systems. There’s the daytime system that you get to see on your tour of the hospital when you prepare for surgery. That hospital is filled with people. Virtually all services are readily available.

Then there’s the weekend and nightime hospital that we refer to as the “off hours” hospital. That hospital has the youngest, least experienced nurses. It has fewer mission critical services. It has fewer lab personnel and support personnel. It has fewer professionals such as pharmacists, nurses and doctors. In some cases the staffing differences are sufficient to become inadequacies. In some cases your care may be compromised. Hospitals persist in this staffing and care model inspite of clear evidence that the bulk of sick patients arrive at night and on weekends.

Academic medical centers have few attending physicians in the hospital at night. That means that while you are in the intensive care unit you receive your immediate care from residents and some really smart medical students. The attending physician is only a phone call away, but that phone call may not be made until it’s too late. For example- I remember a night many years ago when I was on call for the pediatric intensive care unit (PICU). I heard nothing from the resident but about midnight my phone rang. The patient’s parent was calling to tell me what was happening. Sure enough it was going badly and the resident did not realize the dangerous impending changes. It took two days be we changed over to in-house attending coverage of the PICU. Now, fifteen years later the unit still provides in-house attendings and, I believe, better care.

The point is, patients need to ask about nursing ratios for each shift. They need to ask who will answer calls at night- their physician or just an “on-call” physician. They must develop and understanding about the roles of medical students, residents, and other trainees before they start care.

Physicians often respond to the day-night dichotomy with “well it’s always been that way” or I learned that way whay can the young guys?” It wasn’t OK 25 years ago when I learned. It’s simple. It’s not OK to allow vulnerable patients to be cared for in inadequate facilities with under-skilled residents and inadequate supervision. I am always amazed when I see patients come for elective operations late in the evening or at night or on weekends. Clearly the surgeon has not informed them about the skeleton crew, the lack of suport staff, the lean lab abilities. Likewise the surgeon hasn’t told them that he’s been operating for 16 hours already and isn’t up to speed any more. I rarely volunteer how long I’ve been operating but I always answer when asked. A few patients wisely decide to wait.

Patients must ask tough questions and be demanding of the care they deserve. It’s your health, take care and take charge.

What do all those letters mean?

Your doctor has two or more letters behind his/her name. Did you ever stop to think what those mean?

Let’s start with the common ones relating to medical school:
M.D.- this is the usual American Doctor of Medicine (from the latin Medicinae Doctor). Each of these physicians has graduated from an accredited (or equivalent) medical school. Virtually every jurisdiction in the US requires that licensee complete a bachelors degree (or substantial undergraduate education). This is the degree conferred by essentially every American medical school. In contrast, the M.D. is actually a higher degree in some foreign contries indicating substantial post-medical school education.

D.O.- Doctor of Osteopathic Medicine. Osteopathic medical schools are largely indistinguishable from allopathic (MD) medical schools with one exception. Osteopathic medical schools continue to teach manipulation similar to that used by chiropractors. Most “osteopaths” do not use manipulation routinely after graduation. Many osteopaths have post-graduate training in allopathic residencies. No states in the US distinguish between MD and DO degrees. Both are referred to as doctor.

Now the titles get more colorful:
M.B. B.S.- Bachelor of Medicine and Bachelor of Surgery. This is the combination of two degrees conferred primarily by English and (formerly)commonwealth countries. It is an undergraduate degree in that students generally go straight from high school to a professional school. The school encompasses five or more years of study. Graduates are generally recognized as “doctor.”

There are many forms of MBBS. The most interesting comes from McGill University in Canada. M.D. C.M.- Medicinae Doctorem et Chirurgiae Magistrum (Doctor of Medicine, Master of Surgery). A fancy name meaning “doctor.” Other Variations also include: MB ChB, BM BCh, BMed, MB BChir, BM BS. Again, all are referred to as doctor.

My favorite medical degree however comes from Ireland. M.B. B.S. B.A.O. The BAO stands for
Baccalaureus in Arte Obstetricia (Bachelor of the Obstetric Art or Bachelor in the Art of Obstetrics). Now thats a cool name.

Many states allow doctors to use “MD” regardless of what their actual degree says. Osteopaths will always distinguish themselves and generally will refuse to use MD.

Be informed. It’s your health.

Reuse Redux

The re-use of single-use medical devices has again attracted the attention of the popular media, this time the Wall Street Journal.

The article quotes a study of devices manufactured by Medtronic. The study found that new devices were of excellent quality but “a majority of reprocessed devices had corroded parts and traces of human hair and protein, bringing into question the effectiveness of the reprocessing efforts.”

This stands in stark contrast to the comments from Kenneth Kizer, MD, MPH who stated “single-use labeling is a real scam for a lot of devices, and by not using reprocessed devices where possible it is wasteful and not environmentally responsive, since these items have to be disposed of as biomedical waste.” Dr. Kizer continues: “The reuse of medical devices that are labeled for single-use only is a well-established and safe practice regulated by the FDA and utilized by most of the top-ranked hospitals in the country.”

This is only partly true. The FDA strictly regulates the original device. The FDA has some oversight for reprocessing but it was only 2002 that the FDA required these devices to be marked as reprocessed. Safety has yet to be definitively determined. Top hospitals re-use to save money, not to improve care. After all what patient would say his/her care is improved by implanting “corroded parts and traces of human hair and protein” into him/her? Some hospitals may be concerned about waste material but only because they pay to haul it away.

For now the safest thing for patients is to insist on disclosure of the use of reprocessed devices. If reprocessed devices are to be used ask about cost differences to you the patient. Do not hesitate to insist on new devices- especially if there’s no cost difference and now demonstrable equality of quality.

It’s your health. Take it seriously and take care.