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by Chris Emery, Contributing Writer, MedPage Today

A large number of U.S. medical schools say students have posted unprofessional material on Web sites such as MySpace, Facebook, and Twitter, but few schools have adequate policies in place for dealing with such behavior, a new study found.

Of 78 U.S. medical schools that responded to a survey, 60% reported incidents of students posting unprofessional content online, including material that was classified as profane (52% of the respondents), discriminatory (48%), sexually suggestive (38%), or violated patient confidentiality (13%), according to a report in the Sept. 23 Journal of the American Medical Association.

“While most incidents resulted in informal warnings, some were serious enough to lead to dismissal,” Katherine C. Chretien, MD, of George Washington University School of Medicine and Health Sciences, and colleagues wrote.

“However, few respondents reported having professionalism policies that could apply to student online postings and very few of these explicitly mentioned Internet use.”

Chretien and her colleagues acknowledged that Web-based technologies that encourage user generated content, such as social networking sites, blogs, wikis, and media sharing sites (often referred to collectively as “Web 2.0″), have led to innovative tools for healthcare and education.

On the downside, they also noted that people who post unprofessional content can reflect poorly on the institutions with which they are affiliated, and that many industries are grappling with this issue.

“However, the social contract between medicine and society expects physicians to embody altruism, integrity, and trustworthiness,” they wrote. “Furthermore, ethical and legal obligations to maintain patient confidentiality have unique repercussions. Yet, defining unprofessionalism online is challenging; there are no formal guidelines for physicians.”

To that effect, the authors explored the nature and frequency of unprofessional postings by medical students, as well medical school policies governing that behavior.

Of the 130 U.S. medical schools they identified, 78 (60%) responded to a survey on the issue in March and April of 2009, and 47 of these reported one or more incidents of students posting unprofessional content online.

In the year prior to the collection period, 13% of the responding schools reported no incidents, 78% had fewer than five incidents, while 7% had five to 15 incidents, and one school reported some incidents but officials did not know exactly how many.

While six of 46 responding schools reported violations of patient confidentiality online, the more common violations involved profanity, frankly discriminatory language, depiction of intoxication, and sexually suggestive material.

The majority of patient confidentiality violations involved blog posts that described clinical experiences with enough detail that patients could potentially be identified.

Several violations included sexually provocative photographs of students, sexually suggestive comments, and requests by students for inappropriate friendships with patients on Facebook. Other students posted photos of themselves intoxicated or with paraphernalia associated with illicit substances.

Of the schools that responded to a question about current professionalism policies, 38% reported that their policies cover student-posted online content, but most of these policies did not explicitly mention Internet use.

Chretien and colleagues pointed out that some of the behaviors detailed in the study might not be considered unprofessional and that some of the postings fall into a grey area.

While some incidents, such as violation of patient privacy and photos involving illicit drug use, appeared to be clear-cut lapses in professionalism, posts that include profanity or sexual suggestiveness fall into more ambiguous categories.

“Notably, examples of students’ public behaviors that fall into many of these categories have been documented long before the advent of the Internet,” they wrote.

“Some, such as socially inappropriate medical student shows (in which medical students write and perform satirical comedy skits), may serve important coping and stress-release functions during difficult training; however, when disseminated on media-sharing sites such as YouTube or Google Video, they carry the potential for significant public impact and viral spread of content.”

The authors suggested a number of steps that medical schools could take to address the issue:

* The formal professionalism curriculum should include a digital media component, which could include instruction on managing the “digital footprint,” such as electing privacy settings on social networking sites and performing periodic Web searches of oneself.
* Relevant laws related to patient privacy should be incorporated into instruction.
* Assessments of professional competence could include assessment of a student’s digital footprints.
* Medical school residents and faculty should model appropriate Web 2.0 behaviors.
* Faculty should learn the capabilities of the various Web 2.0 applications, if they don’t already understand them.
* Future research should examine existing Internet usage policies, identify policies that work well, and determine the effects of specific policies and classes on students’ online behaviors and professional development.
* Students, residents, and faculty should discuss what medical professionalism means in the era of Web 2.0.

The authors noted that schools responding to the study may have been more likely to have incidents of unprofessional behavior or higher levels of concern than nonrespondents, introducing possible bias into the study.

Other limitations included a lack of available literature on the topic, the absence of student input, and a lack of detailed information on the policies of the schools surveyed.

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The U.S.

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by Monte Ladner, MD

The August 17, 2009 issue of TIME magazine ran a cover story entitled The Myth About Exercise with a subtitle claiming it wont make you lose weight. The author of the article cherry picked bits of data from several scientific studies to make the case that exercise wont help with weight loss, and might even lead to weight gain by causing people to eat more.

The TIME article cites a single set of figures from the Minnesota Heart Survey (MHS) suggesting that more people in Minnesota are exercising today than in 1980. He then conflates this statistic with the observation that the rates of obesity nation-wide are increasing and concludes that this must mean exercise makes us fat.

In the MHS the amount of leisure time physical activity reported by study subjects depended on how the survey question was asked. The MHS also uncovered that the percentage of people who spend more than half their day sitting at work increased from 57% in 1980 to 71% in 2000. The TIME article fails to mention that in the MHS over the 20 years between 1980 2000 the people who did the most exercise gained the least weight. The Minnesota Heart Survey concludes that increased physical activity needs to be part of the solution to the obesity epidemic

The TIME article also draws heavily on research by Dr. Timothy Church of the Pennington Biomedical Research Center in Louisiana. Dr. Church has reported data on over 400 previously sedentary women who were put through supervised exercise programs for six months. The women were divided into 4 groups, a control group and 3 exercise groups. Each of the exercise groups did a very specific amount of exercise under direct supervision. Over the 6-month training period the 3 study groups did 72, 136, and 194 minutes of exercise per week. Exercise sessions alternated between treadmill walking and stationary cycling. The exercise intensity was carefully controlled at 50% of each participants measured maximum oxygen uptake. The subjects were told that this was not a weight loss study and they should not change their diet.

Over the 6-month trial all 3 study groups lost weight associated with their exercise. The 2 lower duration exercise groups both lost exactly as much weight as the researchers calculated they should lose based on the number of calories they were burning. The highest duration exercise group only lost half as much weight as expected based on calories burned while exercising. Dr. Church labeled these people compensators and speculates that they may have started eating more and this reduced the magnitude of their weight loss.

Dr. Church, in an interview with me, is quick to point out that his study was not designed to investigate the phenomenon of compensation and therefore he can only guess as to why the women in the third group didnt lose as much weight as expected. However, they did lose weight and this contradicts the theme of the TIME article that compensatory eating causes exercisers to gain weight. Dr. Church believes that compensation is probably related to people rewarding themselves with food and overestimating how many calories they burn during exercise and underestimating how many calories they eat.

The National Weight Control Registry has followed a group of 5,000 people who lost an average of 66 pounds and sustained their weight loss for an average of 5.5 years. Ninety percent of these people exercise for at least an hour per day.

Exercise is clearly important for health and weight control. I dont know whether the TIME article was just poorly researched and fact-checked or whether it is intentionally misleading to create controversy where none exists.

The bottom line is that this article misleads the public about the value of exercise.

Monte Ladner is an anesthesiologist who blogs at FitnessRocks.org.

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One of the main points of dispute in the health reform debate has been whether to include a newpublic health insurance option.Legislation approvedby three Housecommittees and the Senate, Education, Labor, and Pensions Committee includes such a public option, but theproposal unveiled yesterday by Senate Finance Committe Chairman Max Baucus (D-MT) does not.

Earlier this week, Health Affairs published an article titled “How a New ‘Public Plan’ Could Affect Hospitals Finances and Private Insurance Premiums,” by Allen Dobson, Joan E. DaVanzo, Audrey M. El-Gamil, and Gregory Berger. According to the authors, a new government-run plan could sharply increase private insurance premiums if the plan were to include large portions of those who currently have private health insurance. Because reimbursements offered by the public plan would likely be below hospitals costs, hospitals might attempt to shift costs to those who remain in private plans, thus driving up private premiums.

However, according to Dobson and coauthors, a new public option could bolster hospital margins if enrollment in the plan were dominated by those who are currently uninsured. The study, funded jointly by Dobson Davanzo and Americas Health Insurance Plans, relies on 2007 data from the California Office of Statewide Health Planning and Development.

Editor’s Note: For another take on the public option debate, see this post by David Balto, a senior fellow at the Center for American Progress.

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by Jeff Brandt

There is much confusion about Personal Health Record (PHR) in the market today.

PHRs are divided into three groups; Mobile SmartPhone (mPHR), Cloud Apps, and other devices such as USB and Smartcards . Each type of PHR serves a different purpose and provides a useful and needed service. I will speak to the strengths and weaknesses of each of them.

Web Apps/Cloud PHR

These are browser based systems that need to be connected to the Internet . But, if there is no Internet connection, you can’t get to your health records. Web Apps provide convenient I/O of data and some provide a client interface so that some of your critical data may be viewed on a Web browser. Browsers on Smartphones tend to be slow, hard to read and have limited area access. Mobile PHRs normally provide fewer features than Cloud based systems, but this will be changing as bandwidth
grows and Smartphones acquire more capabilities.

Smartphones and mPHR

Smartphones are cellphones that are more of a computer than phone. As I mentioned, they don’t offer as much power, memory, or bandwidth as Cloud/WebApp systems. Innovation of Smartphones is improving rapidly. Smartphone’s most differentiating feature is portability, they can go anywhere and your health data is always with you. There are many areas all over the world that do not have Internet.

You can find dead zones within ten miles of your home. If you need access to your medical record in one of these areas you will need a mPHR or USB device that is not tethered to the Internet. In most cases, when you need your health information the most, you are not sitting in front of your computer.

A mPHR that connects to a browser based Cloud PHR is a good option, you can manage your health at home and carry your most important data with you. Some mPHR’s also offer ICE (In Case of Emergency), a feature that provides first responders with much needed data about your health and contacts. Note, mPHR that is password protected will be of no help to first responders.

One of the drawbacks of a mPHR can be security. Most mPHR’s on the market today have little or no data security. Passwords alone do not protect data.

USB and SmartCards Devices

These devices are based on USB storage that is a connection to a PC. They are produced in all shapes and sizes from key fobs to credit cards. These devices are good alternatives to a mPHR if you do not have a Smartphone. They are cost effective, small and very portable. The major drawback that I have encountered is that doctors offices are reluctant to let you plug in a USB device into one of their computers because of the potential risk of a computer virus.

PHR’s are fairly new concept in the Medical world and I expect a significant evolution to occur in the next few years due to the current focus. Whether you have a USB device, Cloud PHR, or mPHR, having a PHR is the first step to taking charge of your health.

Jeff Brandt is President of Communication Software, Inc., makers of the motionPHR.

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by Mark Coyne

The core of the health care debate revolves around the perceived spiraling cost of health care in America. There are many quotes in the media, and from politicians, that health care costs are increasing by more than 10 percent a year, and consistently increasing by more than wage growth which is unsustainable in the long term. The basic point being made is correct, the overall cost of health care is increasing by an unsustainable rate versus wages, but the reason for that growth is less well understood. The reason is important as it goes to the root problem in the American health care system and therefore has a huge impact on what the solution should be.

The frequently quoted cost of health care is the amount of premium that an average insured individual or family pays each year. What is important to remember about premiums is that:

1. They are based not only on unit cost, but also utilization, i.e. the amount of units consumed, and therefore their trend includes both aspects.

2. They only show part of the health care cost story since all health care consumers pay additional out of pocket costs.

3. They can be easily reduced by shifting cost away from the premium to out of pocket expenses such as deductibles, co-pays and coinsurance, effectively lowering the premium but not impacting the overall health care cost trend.

A better measure of actual medical care cost trend is to use the same approach used to measure growth in unit costs for any other good or service, i.e. inflation or the consumer price index (CPI). As luck would have it, the government (the Bureau of Labor Statistics) actually monitors this number for the health care industry and issues a Medical Care CPI number that includes all healthcare costs such as physician salaries, hospital costs, medical equipment costs and drug costs.

What is interesting about analyzing this number is that it has stayed remarkably constant over the past 10 years with a variation between 2.8 percent and 4.7 percent from 1997 to 2007. This is certainly nothing like the 10+ percent we hear in from politicians, and is actually only a little more than overall CPI. Bottom line, actual unit medical care costs are not out of control, the procedure you got last year is not that much more expensive this year and your physician is not earning significantly more than they did last year.

So where is the disconnect? Well, as mentioned before, premiums which are typically quoted as representing health care costs include not only the unit price, but also the utilization of units. It doesnt take a genius to draw the conclusion that if underlying unit costs are relatively consistent and below the growth trend of premiums, then what must be changing is the amount of units that are being consumed each year. It is not that the medical procedure you had last year is costing more, its that you are receiving more of them than you did last year, that is why your premium keeps going up!

Of course, I dont mean this literally, you may not think that you are receiving any more care than you did before, but when aggregated to the level of an insurance pool and averaged out across every member of the pool, as a group more care is being delivered than in the prior year.

Why is this important? Because it shows that solutions that focus only on reducing the underlying unit cost while ignoring the utilization will ultimately fail to have any long-term impact. For example, government or insurer attempts to simply reduce costs by reducing payments for a service will not change the basic upwards trend, it will simply delay it, distort the trend temporarily and ultimately result in payments for services that are below cost (some would argue that Medicare is already at this point).

This is perhaps the most important place to start when understanding the problems in health care. Unfortunately, the solutions shift from the typically popular ones of insurance company bashing, medicare payment reductions, increasing coverage, improving benefits, etc. to a stark understanding that we need to address the processes of rationing health care, improving population health, and increasing the financial responsibility of individuals in their health care so they do not perceive it as free once a premium check is paid.

These are politically difficult issues to address, so dont expect the politicians to tell you about them any time soon, but unless you see direct attempts in the health care reform to address these issues you can be sure that your premiums will continue to up.

Mark Coyne is President of Zepherella.

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After decades of teaching, I view everything around me as a final exam and assign it letter grades.

Naturally, I graded President Barack Obamas speech as well. The overall grade is A, a highly respectable grade at Princeton, although there is variation around this overall average for the different themes in the speech.

The elegance and force of the delivery deserved a clear A, and one slouching toward an A+. I do not grade it A+ mainly because our Dean frowns at throwing around A-plusses lightly.

The president does, however, deserve a clear A+ for reminding Americans so clearly and forcefully of the moral dimension of health reform, assisted in that task by the late Senator Ted Kennedys eloquent farewell letter. One may disagree with these two gentlemens policies, but one should not ever doubt their compassion for this countrys less fortunate people. Americans never cease to remind the rest of the world that Americans are the most generous people on earth. The president reminded us that it would be nice if we actually owned up to that boilerplate in our own health care system.

Grade On The Public Plan

I had to agonize over the proper grade on the section dealing with the public health plan. As I understood that section of the speech, President Obama told the progressive wing of the Democratic party: You certainly have a persuasive case in pushing for a public plan, a line of reasoning I share, but lets face it folks: it aint gonna happen, nor is it the sine qua non of what we are trying to achieve with this health reform.

My colleagues in the Political Science Department probably would score it as a solid A, because it may well have been politically skillful. Perhaps it will suffice to soothe the sentiments of the progressive Left.

As an economist, however, I have some trouble buying the presidents argument that a new public plan, added to the existing large number of private insurance vehicles, would inject more competition into the market for health insurance and that more competition in that market would help lower the cost of health care.

Let us note at the outset that the huge profits many critics of the private insurance industry imagine in their railing against the industry actually are not that huge. Fortune magazine lists Insurance and Managed Care at number 35 among the 50 most profitably industries in 2008, with an average profit margin (net after-tax profits as a percentage of revenue) of 2.2%. I find that margin on the low side. In normal times, the margin ranges between 3% and 5%. Even so, lowering that margin some through more competition would not yield much of a harvest in cost control.

To be sure, if a new public plan simply piggybacked on Medicare payment rates, it might help lower health spending I say, might other things being equal. There is market power in monopsony (the economists word for a single buyer), at least insofar as prices are concerned.

But as the sorry role of the sustainable growth rate (SGR) mechanism for physician payments under Medicare shows, without better control over the volume of care paid for, the ability to control prices has its limits, too. And if members of Congress believe that a new public plan would experiment with smart ways to control that volume so as to increase the value received for the dollar, one may ask why Congress has not allowed the already existing public plan, Medicare, to show the way. Why wait to delegate the whole task to an as yet nonexistent new public plan?

But what if the new public plan also had to negotiate over payments with providers, like any other insurance plan to create the proverbial level playing field?

Here it must be remembered that the U.S. market for health care services is rife with a system of price discrimination under which the prices insurers (and individuals) pay hospitals and physicians depend solely on the relative bargaining strength of the negotiating parties. So I try to imagine now how having one more insurance carrier in a given market area, with each insurer now claiming a smaller market share of patients whom they could funnel to a particular provider, will enable each of them or at least the new plan alone to get lower prices from the providers of health care. I have trouble imagining it.

My theory is that the more insurers there are in a given market, the smaller will be each insurers market share, and the easier it will be for providers especially those consolidated into large medical group practices or hospital systems simply to blow off any insurers seeking large discounts off charges. In plainer English, the larger the number of insurers, the more each of them will morph into a mouse that roars.

It is also the reason why I am also not persuaded of the idea that the smallish regional cooperatives now being discussed in the Senate will do anything for cost control. These co-ops may possibly be a good political fig leaf in the current context, but they are unlikely to do anything to control U.S. health care spending. They would be likely to be not even mice that roared, but baby mice that squealed.

Speaking of relative bargaining power in the market for health care, one should note that even large insurers with a large market share in a market area might not have all that much bargaining power. I recall the bitter negotiations over payments between WellPoint and Sutter Health in California around the year 2000, in which WellPoint ultimately was brought to heel because patients and their employers sided with their doctors, who were affiliated with Sutter. Could WellPoint really hope to sell health insurance in Northern California without having Sutter Health (or Catholic Healthcare West, for that matter) in its network?

Similarly, although Blue Cross and Blue Shield of Massachusetts is a large player in that market area, it faces an equally large and powerful player in HealthPartners. Massachusetts is known for its high health spending — among the highest in the nation. Can one sell health insurance in Boston without HealthPartners in the network?

Finally, as a bit of a digression, while were on the subject of private insurance and cost control, the opponents of a public health plan frequently argue that such a plan would underpay hospitals and doctors, forcing the latter to recover the shortfall from private insurers through a cost shift estimated by Milliman Inc. to be around $90 billion a year.

If that is true, however, then one may ask the following question: If the private plans cannot resist increased prices as a result of this particular cost shift, how then can they resists any price increases justified to them by any cost, whatever its origin? How, for example, could they resist picking up the tab for the so-called medical arms race by which hospitals compete? I find this an intriguing question and invite comments thereon.

Now, with all that having been said, I would grade the section of the presidents speech dealing with the public health plan a B or C+ on the economics of the issue, but I am open to persuasion by a second grader from the Political Science Department that it should be assigned a solid A. As is our wont in the academy, wed probably settle on an A.

I would more easily accede to a solid A if President Obama had said that the major attraction of a public plan might not even be its alleged ability to control costs but, instead, that it can offer those Americans who crave it a stable, permanent, and easily portable health insurance product. A challenge for the private insurance industry in the half-decade ahead will be to provide Americans with that stability and permanence in the nongroup health insurance market.

Grades On Cost And Financing

The president gets high marks for clarity in telling us roughly how much he is willing to spend on health reform ($900 billion or so over the next decade) and that he intends to finance it fully. So now we know that.

I am stunned, however, that he missed the opportunity — or voluntary shied away from it to remind Americans that in 2003 President George W. Bush and his then Republican Congress passed a huge new health care entitlement without giving a moments thought on how to finance it: the Medicare Modernization Act of 2003 (MMA).

Current projections are that MMA will add $1 trillion to the federal deficit during the next decade (201019) for drugs alone, and close to $1.2 trillion if the president does not succeed in trying to harvest the roughly $170 billion or so that Medicare Advantage (private managed care) plans will receive in the form of a subsidy over and above what beneficiaries in these plans would have cost taxpayers had they stayed in traditional Medicare.

Its nice to be a nice guy in a speech of this sort, but I just have to dock the president a few points of his grade on this section for failing to exploit this splendid opportunity.

I cannot give the president a good grade, either, for clarity on how exactly he proposes to finance the proposed $900 billion. Can it really be done just by redirecting funds already flowing from government into health care now? Is that clinically feasible? Is it even vaguely politically feasible? What would it imply for cuts to projected Medicare spending? Are added taxes for high income earners off the table now?

Similarly, many Americans with family incomes of, say, $60,000 to $80,000 must have come away from the speech wondering whether they have anything at all to gain from the proposed health reform. What in the ways of subsidies could be granted American families for $900 billion over the next 10 years?

Once again, my friends in the Political Science Department might lecture me that the clarity economists seek in such matters is out of place in the political arena that the president went as far as is politically savvy in this case. After all, complete lack of clarity all along on the cost of our two wars abroad made them much more politically palatable.

I would defer to my colleagues in negotiating a grade. As an economist, however, I would find it hard to grade the entire section on cost and financing as more than a B, going into the negotiation, and even that only in a fit of generosity in grading.

Grade On Malpractice Reform

Finally, I would give the president an A for at least waving an olive branch towards those Americans who believe that malpractice reform by itself would be a major instrument of cost control in our health system. It would be helpful, for starters, to experiment vigorously with alternative forms of dispute resolution. I find mere caps of awards for pain and suffering too much of a meat-ax approach.

We know that malpractice premiums are only a small percentage of total health spending. It is often alleged, however, that possibly as much as 15% of total personal health spending in the United States may originate in defensive medicine. Could we perhaps harvest that money through malpractice reform?

Perhaps. I am not aware of any robust empirical evidence for the claim that malpractice insurance is a major cost driver. Instead, I am reminded of a tongue-in-cheek talk I gave some 15 years ago or so to the American Medical Association, counseling the doctors assembled there by all means to lament the malpractice problem loudly, but not so loud that God might hear them and do away with the phenomenon. Would they then cheer, I asked them, to see their revenue decline by 15 percent? I recall many blank stares.

If I had to bet, I would wager that malpractice reform might yield some small cost savings, but not a sizable amount. Which is not to say, of course, that there are not other, nonmonetary reasons to replace the tort system in health care, as in many other forums of economic activity, with alternative forms of dispute resolution. The health policy research community has come forth with such proposals for over three decades now.

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by Crystal Phend, MedPage Today

Every 10 years a doctor should be the patient, said my doctor, squeezing me into pair of compression stockings that would make a sausage casing seem spacious by comparison.

Seems like a good idea, I thought, as I lay there on the table feeling optimistic about the opportunity for first-hand experience.

It was my first minor elective procedure aside from dentistry, and required a week of 24-hour, 20- to 30-mm Hg pressure to ward off any potential thromboembolism formation (along with my physicians urging for early mobilization).

I had done my homework and gone in with a list of questions about complication rates, long-term effects, and expected results, though I still felt a little nervous about whether I should have shopped around more.

But I wasnt prepared for compression stockings.

Sure, Id written plenty about thromboembolism prophylaxis anticoagulants, antiplatelet drugs, and mechanical devices. I felt pretty comfortable, even knowledgeable, about graduated compression stockings as a means of prevention.

The experience, though, is rarely mentioned in more than broad terms in studies Ive covered. Researchers have told me about some of the difficulties older patients face in trying to use them. Not until I tried them myself, though, did this really hit home.

For one thing, theyre incredibly hot and uncomfortable in summer. Any joint ended up with bunched-up material cutting into the skin after a certain number of hours, which during the night would make my ankles itch or hurt.

As I struggled to pull them on, yanking while the stockings fought back by snapping like a giant rubber band, I exclaimed that it would be impossible to put these if I were weak or frail.

A sense of empathetic commiseration developed for an older friend who has worn compression stockings continually for years because of painful varicose veins. I couldnt wait for my temporary tribulation to be over.

Does this bias me in my reporting of post-surgical thromboprophylaxis? Would I be more favorable toward pharmacologic methods?

I dont think so. Rather, I know the practical issues and quality of life concerns to ask about, much like a journalist with diabetes who I consider to have an in when covering the American Diabetes Association meeting or another who reported here on his unique perspective after participating in a weight loss trial.

For a physician, I can only imagine what this kind of empathy and understanding would do for bedside manner.

Crystal Phend is a staff writer at MedPage Today and blogs at In Other Words, the MedPage Today staff blog.

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An article that appeared in the Los Angeles Times in late August looked at the idea that one of the keys to providing better medical care at lower costs may be house calls.

Should we bring house calls back?

There is some compelling data like an in-home doctors-visit program for Medicare patients at the Virginia Commonwealth University Medical Center that cut the length of hospital stays and saved the hospital millions of dollars. A similar program through the Department of Veterans Affairs cut hospital inpatient admissions by more than one-quarter, and total days in the hospital by more than two-thirds.

Elderly patients with multiple conditions who have trouble getting to their doctors office are often more likely to end up in the hospital. It’s worth noting that the sickest 10 percent of Medicare recipients account for two-thirds of total spending. In-home visits could take the place of unnecessary and costly hospital stays and help prevent equally expensive re-admissions to the hospital.

But home visit programs require an upfront financial commitment to achieve long-term savings, which Medicare has been reluctant to fund. Many doctors who want to incorporate home visits in their practice cant afford to.

Politicians in the health reform discussion have proposed increasing funding to house call programs. For the sake of keeping our seniors healthy, let’s hope this funding survives the debate.

I encourage you to listen and vote in this weeks poll, located both below, and in the upper right column of the blog.

Please suggest future ReachMD Poll topics by emailing Poll@ReachMD.com.

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by Patricia B. Allen, MBA, RN

What would you differently tomorrow if you had a violent episode in your emergency department today?

Violence in the ED is a growing and alarming phenomenon. A recent survey conducted by the Emergency Nurses Association (ENA) revealed that 25 percent of the RN respondents report experiencing physical violence more than 20 times in the past three years and 20 percent of the respondents revealed encountering verbal abuse more than 200 times in the past three years.

A recently released article by the Journal of Nursing Administration discusses and supports – the results of the ENA survey. ED Violence is a serious threat that needs immediate attention. ED nurses and physicians are on the front lines of aggression, violence and abuse from patients, families, visitors, gang members.

What puts the ED at such high risk?

The main risk factor that places EDs at risk is that hospitals do not recognize the threat, reality or prevalence of ED violence. A large number of hospitals and their administrators believe that violence cant happen here. But violence can happen no matter the size or location of the hospital. Being unprepared and downplaying the risk places hospitals in an extremely vulnerable position.

The EDs chaotic environment, EMTALA, crowding and boarding, the closure of many inpatient psychiatric hospitals, the lack of primary care physicians and clinics, the growth of gang activity, limited staff de-escalation training and inadequate triage resources/training all impact the ED, imperiling those EDs and hospitals that are uninformed and unprotected.

The absent dialogue

Hospital administrators and CEOs generally do not seem to regard ED violence as one of their top concerns; herein lies the problem. ED management must do a better job of educating and communicating ED violence and near-miss violent episodes to the CEO and the CEO must in turn, implement, as a start, violence incident reporting mechanisms and empower the ED staff to report violence without fear of reprisal and with a good-faith commitment to rapidly make important and necessary safety and security improvements.

It is crucial that the ED staff feels safe at work. I encourage you to ask your ED staff if they are safe or feel safe at work in the emergency department of your hospital.

A 3-step beginning

1. A risk assessment of the ED will help you evaluate doors and other access points, the presence or absence of duress alarms, an overhead paging code to alert a red team for rapid, additional assistance in the ED in the event that a violent episode erupts, plus the identification of other risk factors in your facility. Fix the most egregious problems as your budget permits.

2. Communication. Bump up the communication with the CEO and hospital administrators using statistics from your ED. Communicate with the CEO in language that they understand using numbers and statistics. Communicate the requirement that violent episodes are to be reported and implement a method to do so, guaranteeing that there is no threat or concern for reprisal. Be certain to follow-up with the person reporting the violence.

Consider the adoption of a customer service policy and hospitality strategy. Communicating with patients in the waiting room to inform them of their place in the queue or reasons for delays can reduce the potential for angry outbursts or outright violence. Long waits in the waiting room to see a physician for care is one of the documented reasons for violent patient eruptions.

Revamp your triage area and re-educate the nurses and techs who are assigned to triage. The triage RN is a key staff member in thwarting potential violence. Communicate with the ED staff and devise a violence prevention plan.

3. Does your facility warrant the consideration of metal detectors and around-the clock security? Talk with the local police department to help evaluate the presence of gangs and crime in your hospitals geographic location. The only failsafe way to eliminate the presence of contraband in the ED is via electronic screening for weapons.

Patricia B. Allen is author of Violence in the Emergency Department: Tools & Strategies to Create a Violence-Free ED.

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