Surgeons’ Opioid-Prescribing Habits are Dangerous, Persistent

As the opioid crisis escalated into an epidemic across the U.S., thousands of surgeons continued to hand out far more pills than needed.

Julie Appleby, Kaiser Health News and Elizabeth Lucas, Kaiser Health News

As opioid addiction and deadly overdoses escalated into an epidemic across the U.S., thousands of surgeons continued to hand out far more pills than needed for postoperative pain relief, according to a KHN-Johns Hopkins analysis of Medicare data.

Many doctors wrote prescriptions for dozens of opioid tablets after surgeries — even for operations that cause most patients relatively little pain, according to the analysis, done in collaboration with researchers at Johns Hopkins Bloomberg School of Public Health. It examined almost 350,000 prescriptions written for patients operated on by nearly 20,000 surgeons from 2011 to 2016 — the latest year for which data are available.

Some surgeons wrote prescriptions for more than 100 opioid pills in the week following the surgery. The total amounts often exceeded current guidelines from several academic medical centers, which call for zero to 10 pills for many of the procedures in the analysis, and up to 30 for coronary bypass surgery.

While hundreds of state and local lawsuits have been filed against opioid manufacturers, claiming they engaged in aggressive and misleading marketing of these addictive drugs, the role of physicians in contributing to a national tragedy has received less scrutiny. Research shows that a significant portion of people who become addicted to opioids started with a prescription after surgery.

In sheer numbers, opioid prescribing in the U.S. peaked in 2010, but it remains among the highest in the world, according to studies and other data.

In 2016, opioids of all kinds were linked to 42,249 deaths, up from the 33,091 reported in 2015. The opioid-related death rate jumped nearly 28% from the year before, according to the CDC.

Yet long-ingrained and freewheeling prescribing patterns changed little over the six years analyzed. KHN and Johns Hopkins examined the prescribing habits of all U.S. surgeons who frequently perform seven common surgical procedures and found that in the first week after surgery:

  • Coronary artery bypass patients operated on by the highest-prescribing 1% of surgeons filled prescriptions in 2016 exceeding an average of 105 opioid pills.
  • Patients undergoing a far less painful procedure — a lumpectomy to remove a breast tumor — were given an average of 26 pills in 2016 the week after surgery. The highest-prescribing 5% of surgeons prescribed 40 to 70 pills on average.
  • Some knee surgery patients took home more than 100 pills in the week following their surgery.

Those amounts — each “pill” in the analysis was the equivalent of 5 milligrams of oxycodone — are many times what is currently recommended by some physician groups to relieve acute pain, which occurs as a result of surgery, accident or injury. The analysis included only patients not prescribed opioids in the year before their operation.

“Prescribers should have known better” based on studies and other information available at the time, said Andrew Kolodny, co-director of opioid policy research at Brandeis University and director of the advocacy group Physicians for Responsible Opioid Prescribing.

While the dataset included only prescriptions written for patients on Medicare, the findings may well understate the depth of the problem, since doctors are more hesitant to give older patients the powerful painkillers because of their sedating side effects.

Surgeons’ prescribing habits are significant because studies show that 6% of patients who are prescribed opioids after surgery will still be taking them three to six months later, having become dependent. The likelihood of persistent use rises with the number of pills and the length of time opioids are taken during recuperation.

Also, unused pills in medicine cabinets can make their way onto the street.

Dr. Marty Makary, a surgical oncologist at Johns Hopkins, admits that he too once handed out opioids liberally. Now he is marshaling a campaign to get surgeons to use these powerful painkillers more consciously and sparingly. “I think there’s an ‘aha’ moment that many of us in medicine have had or need to have,” he said.

But old habits are hard to kick.

KHN contacted dozens of the surgeons who topped the ranks of opioid prescribers in the 2016 database. They hailed from small, community hospitals as well as major academic medical centers. The majority declined to comment, some bristling when questioned.

Look Up Opioid Prescribers: Search KHN Database By Doctor, Hospital

Some of those surgeons were critical of the analysis, saying it didn’t take into account certain essential factors. For example, it was not possible to determine whether patients had complications or needed higher amounts of pain medication for another reason. And some surgeons had only a handful of patients who filled prescriptions, making for a small sample size.

But surgeons also indicated that the way they prescribe pain pills was less than intentional. It was sometimes an outgrowth of computer programs that default to preset amounts following procedures, or practice habits developed before the opioid crisis. Additionally, they blame efforts in the late 1990s and early 2000s that encouraged doctors and hospitals to consider pain as “the fifth vital sign.” A major hospital accrediting group required providers to ask patients how well their pain was treated. Pharmaceutical companies used the fifth vital sign campaign as a way to promote their opioid treatments.

Makary, who oversaw the analysis of the Medicare dataset, said that, while opioid prescribing is slowly dropping, to date many surgeons have not paid enough attention to the problem or responded with sufficient urgency.

Dr. Audrey Garrett, an oncologic surgeon in Oregon, said she was “surprised” to hear that she was among the top tier of prescribers. She said she planned to re-evaluate her clinic’s automated prescribing program, which is set to order specific amounts of opioids.

KHN will analyze data for 2017 and subsequent years when it becomes available to follow how prescribing is changing.

Prescribing Patterns Highlight What’s At Stake 

The analysis examined prescribing habits after seven common procedures: coronary artery bypass, minimally invasive gallbladder removal, lumpectomy, meniscectomy (which removes part of a torn meniscus in the knee), minimally invasive hysterectomy, open colectomy and prostatectomy.

Across the board, the analysis showed that physicians gave a large number of narcotics when fewer pills or alternative medications, including over-the-counter pain relief tablets, could be equally effective, according to recent guidelines from Makary and other academic researchers.

On average, from 2011 to 2016, Medicare patients in the analysis took home 48 pills in the week following coronary artery bypass; 31 following laparoscopic gallbladder removal; 28 after a lumpectomy; 41 after meniscectomy; 34 after minimally invasive hysterectomy; 34 after open colon surgery; and 33 after prostatectomy.

According to post-surgical guidelines spearheaded by Makary for his hospital last year, those surgeries should require at most 30 pills for bypass; 10 pills for minimally invasive gallbladder removal, lumpectomy, minimally invasive hysterectomy and prostatectomy; and eight pills for knee surgery. It has not yet published a guideline for open colon surgery.

The Johns Hopkins’ doctors developed their own standards because of a dearth of national guidelines for post-surgical opioids. They arrived at those figures after reaching a consensus among surgeons, nurses, patients and other medical staff on how many pills were needed after particular surgeries.

Hoping to reduce overprescribing, Makary is preparing to send letters next month to surgeons around the country who are among the highest opioid prescribers under a grant he received from the Arnold Foundation, a nonprofit group whose focus includes drug price issues. (Kaiser Health News also received funding from the Arnold Foundation.)

Even if the prescription numbers have fallen since 2016, the amounts given today are likely still excessive.

“When prescribing may have been five to 20 times too high, even a reduction that is quite meaningful still likely reflects overprescribing,” said Dr. Chad Brummett, an anesthesiologist and associate professor at the University of Michigan.

Brummett is also co-director of the Michigan Opioid Prescribing Engagement Network, a collaboration of physicians that makes surgery-specific recommendations, many of them in the 10- to 20-pill range.

“Reducing unnecessary exposure is key to reducing the risk of new addiction,” said former Food and Drug Administration commissioner Scott Gottlieb. In August 2018, when Gottlieb was at the agency’s helm, it commissioned a report from the National Academy of Sciences on how best to set opioid prescribing guidelines for acute pain from specific conditions or surgical procedures. Its findings are expected later this year.

“There are still too many 30-tablet prescriptions being written,” said Gottlieb.

Healers Sowing Disease?

Naturally, surgeons rankle at the idea that they played a role in the opioid epidemic. But studies raise serious concerns.

Transplant surgeon Dr. Michael Engelsbe, director of the Michigan Surgical Quality Collaborative, points to the study showing 6% of post-op patients who get opioids for pain develop long-term dependence. That means a surgeon who does 300 operations a year paves the way for 18 newly dependent people, he said.

Many patients do not need the amounts prescribed.

Intermountain Healthcare, a not-for-profit system of hospitals, clinics, and doctors in Utah, began surveying patients two years ago to find out how much of their prescribed supply of opioids they actually took following surgery.

“Globally, we were overprescribing by 50%,” said Dr. David Hasleton, senior medical director.

But Intermountain approached individual doctors carefully. “If you go to a prescriber to say, ‘You are overprescribing,’ it never goes well. A common reaction is, ‘Your data is wrong’ or ‘My patients are different than his,’” said Hasleton.

For the analysis, KHN attempted to contact more than 50 surgeons whose 2016 numbers ranked them among the top prescribers in each surgical category.

One who did agree to speak was Dr. Daniel J. Waters, who 13 years ago had his chest cut open to remove a tumor, an operation technically similar to what he does for a living: coronary artery bypass.

“So I have both the doctor perspective and the patient perspective,” said Waters, who practices in Mason City, Iowa.

In 2016, Waters’ Medicare bypass patients who filled their prescriptions took home an average of nearly 157 pills each, according to the KHN-Johns Hopkins analysis.

“When I went home from the hospital, 30 would not have been enough,” said Waters of the number recommended by the Hopkins team for that surgery.

But he said he has recently curbed his prescribing to 84 pills.

Nationally, the average prescription filled for a coronary artery bypass was 49 pills in 2016 and had changed little since 2011, the analysis shows.

Others who spoke with KHN said they had developed the habit of prescribing copiously — sometimes giving out multiple opioid prescriptions — because they didn’t want patients to get stuck far from the office or over a weekend with pain or because they were trying to avoid calls from dissatisfied, hurting patients.

In the KHN-Johns Hopkins data, the seven patients of Dr. Antonio Santillan-Gomez who filled opioid prescriptions after minimally invasive hysterectomies in 2016 received an average of 77 pills each.

A gynecologic oncologist, Santillan-Gomez said: “I’m in San Antonio, and some of my patients come from Laredo or Corpus Christi, so they would have to drive two to three hours for a prescription.”

Still, he said, since e-prescribing of opioids became more widespread in the past few years, he and other surgeons in his group have limited prescriptions to 20 to 30 pills and encouraged patients to take Tylenol or other over-the-counter medications if they run out. E-prescribing can not only help track patients getting opioids but also reduce the problem of patients having to drive back to the office to get a written prescription.

Dr. Janet Grange, a breast surgeon in Omaha, Neb., said that in her experience, opioid dependence had not been a problem.

“I can absolutely tell you I don’t have even 1% who become long-term opioid users,” said Grange.

The analysis showed that Grange had 12 opioid-naïve Medicare patients who had a lumpectomy in 2016. Eight of them filled prescriptions for an average of 47 pills per patient.

She called Johns Hopkins’ zero-to-10-pill pain-control recommendation following that procedure “miserly.”

The Pendulum Swings

Some of the higher-prescribing surgeons in the KHN-Johns Hopkins analysis reflected on their potential contribution to a national catastrophe and are changing their practice.

“That is a shocking number,” said oncologist Garrett, speaking of the finding that 6% of patients who go home with opioids will become dependent. “If it’s true, it’s something we need to educate physicians on much earlier in their medical careers.”

Garrett, in Eugene, Ore., said she has cut back on the number of pills she gives patients since 2016. The KHN-Johns Hopkins analysis showed that seven of her 13 opioid-naïve Medicare patients undergoing minimally invasive hysterectomies filled a prescription for opioids in 2016. Those patients took home an average of 76 pills each.

Johns Hopkins guidelines call for no more than 10 opioid pills following this procedure, while Brummett’s Michigan network recommends no more than 15.

Surgeon and researcher Dr. Richard Barth, once a heavy prescriber himself, said that his own experience convinced him that physicians’ preconceptions about how much pain relief is needed are often way off.

The analysis showed his lumpectomy patients in 2013 filled an average of 33 pills in the week after surgery. By 2016, that average had dropped to seven pills. Many patients, he said, can do just fine after lumpectomy with over-the-counter medications — and often no opioids at all.

The key, he said, is to set patients’ expectations upfront.

“I tell them it’s OK to have a little discomfort, that we’re not trying to get to zero pain,” said Barth, who is chief of general surgery at Dartmouth-Hitchcock Medical Center and has published extensively on opioid prescribing.

After lumpectomy, “what I recommend is Tylenol and ibuprofen for at least a few days and to use the opioids only if the discomfort isn’t relieved by those.”

Indeed, the data analysis showed that a significant number of patients given prescriptions for opioids never filled them because they don’t need that level of pain relief.

Between 2011 and 2016, for example, only 62% of lumpectomy patients in the analysis filled prescriptions, similar to hysterectomy patients.

In 2016, patients of Dr. Kimberli Cox, a surgeon in Peoria, Ariz., were prescribed about 59 pills in the week following lumpectomy, well above the recommendations from both Johns Hopkins and others.

But the KHN-Johns Hopkins analysis of that year’s data shows that half of her patients never filled a painkiller prescription — a fact she acknowledges has changed her thinking.

“I am now starting to prescribe less because many patients say, ‘You gave me too many’ or ‘I didn’t fill it,” she said.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Your Practice’s Online Presence Matters

The patients have spoken—an online presence and well thought out customer experience are critical components when it comes to choosing a physician or practice.

The patients have spoken—an online presence and well thought out customer experience are critical components of their choice in and retention of a practice and physician, or so says the recent Customer Experience Trends in Healthcare report from doctor.com.

The study, in which 1,718 U.S. adult patients participated, found that 80% of consumers used the internet to make a healthcare-related search in the past year, and that 81% of patients will read reviews about a provider, even after they have been referred to them. If your practice is not online—or worse, if you have a negative presence online—your practice could be suffering. 90% of survey respondents stated that will frequently or always change their mind about a referral due to the provider’s poor or weak online reputation (a rating of less than three out of five stars), and 60% stated they would not book with a provider with poor quality reviews. That rings true across all age groups, too, not just the tech-savvy millennial population—of those respondents over age 60, 76% said they have used the internet to make a healthcare related search in the last year, and 90% will change their mind about seeing a referred healthcare provider with a rating of less than 3 stars online.

It isn’t just about reputation, though. Patients are also seeking a seamless digital experience, as well. 45% of respondents stated they prefer to use digital methods, such as a patient portal, to request an appointment, and 42% will choose a provider exclusively for access to this. Another 71% said they prefer appointment reminders via text or email, really driving home the importance of integrating digital tools for a more complete customer experience.

If you have yet to take your online presence seriously, now is the time, for as technology evolves—and it does at a rapid rate—users of all ages are quick to adopt it, and they want to see it everywhere, even in their healthcare.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Do “Rude” Surgeons See Worse Patient Outcomes?

Not all surgeons are unprofessional. But when they are, do their patient outcomes suffer? It seems so, according to a new study published this week.

We can just get this out of the way, right up front: No, not all surgeons are jerks. Or unprofessional. Or think that they are God. But the stereotype persists. Surgeons, whether it is earned or not, do not have the strongest reputation for being warm, friendly paragons of professionalism. And, when this is true, when they are actually that way, it may mean worse outcomes for their patients, or so says a new study published in JAMA Surgery.

The study posed the following question: Do patients of surgeons with a higher number of coworker reports about unprofessional behavior experience a higher rate of postoperative complications than patients whose surgeons have no such reports?

The answer? It seems so.

For the study, researchers examined data on nearly 13,700 surgical patients and 202 surgeons from the National Surgical Quality Improvement Program, and analyzed post-op reports to identify any complication during the 30-day postoperative period, as well as whether or not the surgeons’ colleagues reported four kinds of unprofessional behavior: concerns about poor or unsafe care, unclear or disrespectful communication, lack of integrity, and an absence of professional responsibility.

The researchers found that when surgeons had one or more reports of unprofessional behavior during the previous 36 months, their patients were 12% to 14% more likely to experience surgical or medical complications during or following surgery.

The study concludes that, “It would seem that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase their patients’ risk for adverse outcomes.”

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Hiring Spotlight: CoreMedical Group

In this Hiring Spotlight, learn more about CoreMedical Group and the thousands of openings they have available for nurses, therapy professionals, and physicians.

Welcome to the Hiring Spotlight, a feature that takes a deeper look at companies that are offering excellent opportunities for you across the country.

Company Profile

For more than 25 years, CoreMedical Group has been a leader in healthcare staffing and recruiting for registered nurses, physical and occupational therapists, speech language pathologists, respiratory therapists, physicians, and medical management roles for placement in hospitals and healthcare facilities across the country. Their mission to “Connect People, Improve Lives, and Give Back” is the foundation of everything they do. With thousands of openings across all 50 states, including Alaska and Hawaii, if the right position for you is out there, you can very likely find it with CoreMedical Group.

Take a look at a handful of their openings below, or view thousands of CoreMedical Group’s available jobs by clicking here.

Featured Openings

Nursing Jobs:

RN, Med/Surg $10K BONUS – Muskogee, OK

Immediate need for experienced Med/surg RN’s to join a leading hospital system. Prefer RN’s with 2+ years clinical experience in Medical/Surgical unit or related specialty. Active OK license, BLS Certified.

RN – Registered Nurse – Honolulu, HI

Client in HI seeking HI- TELE (RN) to work 12 hour shifts, Rotating Day / Night. Must work weekends. May be asked to be on-call at times. If voluntary on-call from regular scheduled shift, and called to report, hours will be paid at straight time for regularly scheduled shift.

RN, Nurse, Critical Care, ICU – Frisco, TX

Immediate need for a Registered Nurse with 2 or more years Critical Care / ICU experience in a fast-paced, high acuity setting to join a leading hospital system. BSN Degree preferred. ACLS, BLS Certified. Active TX license.

RN – Registered Nurse – Washington, D.C.

Client in DC seeking RN OR (RN) to work Weekends, Days (05:00-08:00)

RN – Registered Nurse – Los Angeles, CA

Client in CA seeking Staff Nurse Inpatient-CVICU/Coronary-Fast Response (RN) to work 07:00 AM to 07:00 PM

Advanced Practice Jobs:

Nurse Practitioner – Houston, TX

Immediate opening for an experienced Acute Care Nurse Practitioner to join a leading hospital. Qualified candidates will have 3 or more years experience. Must have TX License and prescriptive authority.

Physician Assistant – Albuquerque, NM

CoreMedical Group has partnered with a client in New Mexico that needs ongoing coverage for their Urgent Care. If you do not currently have a NM license but are interested, we can help facilitate this process for you.

Nurse Practitioner – Colorado Springs, CO

CoreMedical Group has partnered with a client in Colorado that needs ongoing coverage for their Neonatal program. This opportunity requires an active CO license.

Nurse Practitioner – Altoona, PA

CoreMedical Group has partnered with a client in Western Pennsylvania that needs ongoing APP coverage for their Hospital Medicine program. If you do not currently have a PA license but are interested, we can help facilitate this process for you. Night Shifts 7p-7a. Block Scheduling. Ongoing Need. Full Sub-specialty support. Market Competitive Rates.

Physician Assistant – Santa Clara, CA

CoreMedical Group has partnered with a client in California that needs ongoing coverage for their Urgent Care. If you do not currently have a CA license but are interested, we can help facilitate this process for you. Mon- Fri- 9 hr day- no weekend, no call. Must see all ages. Minor procedures. Market competitive rates.

Therapy Jobs:

Physical Therapist – PT – Portland, OR

Client in OR seeking Temp – PT – Home Health (Days) Portland, OR (PT) to work Days

Occupational Therapist – OT – Syracuse, NY

Client in NY seeking OT – Ongoing Saturdays (OT) to work Days

Speech Language Pathologist – SLP – York, PA

Client in PA seeking Temp – Rehabilitation – Speech Language Pathologist (Days) York, PA (SLP) to work Days

Occupational Therapist Outpatient Clinic – Rock Hill, SC

Immediate need for a Licensed Occupational Therapist to join a dynamic team of therapists. Prefer an OT with 1 or more years of experience working with pediatric patients. SC License.

Physical Therapist – PT – Macon, GA

Client in GA seeking Travel – PT – Physical Therapy (762) – Days (PT) to work 07:00-19:00

Physician Jobs:

Pediatric Practice Physician – Sidney, OH

Seeking a board certified or board eligible Pediatrician to join a very successful practice. Provider will see approximately 20 to 25 patients per day and enjoy a 1 in 4 call rotation with other employed pediatricians. The practice opportunity is about a 95 percent outpatient and 5 percent inpatient opportunity.

Urology Physician – Machias, ME

This is an opportunity to join a critical access, hospital affiliated multi-specialty group in a small town in Eastern Maine. The practice has been going strong for many years and continues to grow and progress with the times. This is a permanent position. Pay Rate median $450,000 annually and will be dependent on qualifications and experience. Incentive compensation based on WRVU generation. Relocation $10-15k. Sign on bonus $25k.

Physician – Sitka, AK

CoreMedical Group has partnered with a client in Alaska that needs ongoing coverage for their Emergency Medicine program. This opportunity requires an active AK license.

Physician – Punta Gorda, FL

CoreMedical Group has partnered with a client in Florida that needs ongoing coverage for their Neuro-Interventional Radiology program. If you do not currently have a FL license but are interested, we can help facilitate this process for you.

Physician – Williamstown, MA

Outpatient Primary Care. Board Certified FM or IM or BE within 2 years. BLS. Mon- Fri- 8a-5p with weekend call. October start date ongoing. Market competitive rates.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Never Say ‘Die’: Why So Many Doctors Won’t Break Bad News

The majority of patients with serious illness receive news in what researchers call a “suboptimal way.” Could training physicians to deliver bad news help?

JoNel Aleccia, Kaiser Health News

PORTLAND, Ore. — After nearly 40 years as an internist, Dr. Ron Naito knew what the sky-high results of his blood test meant. And it wasn’t good.

But when he turned to his doctors last summer to confirm the dire diagnosis — stage 4 pancreatic cancer — he learned the news in a way no patient should.

The first physician, a specialist Naito had known for 10 years, refused to acknowledge the results of the “off-the-scale” blood test that showed unmistakable signs of advanced cancer. “He simply didn’t want to tell me,” Naito said.

A second specialist performed a tumor biopsy, and then discussed the results with a medical student outside the open door of the exam room where Naito waited.

“They walk by one time and I can hear [the doctor] say ‘5 centimeters,’” said Naito. “Then they walk the other way and I can hear him say, ‘Very bad.’”

Months later, the shock remained fresh.

“I knew what it was,” Naito said last month, his voice thick with emotion. “Once [tumors grow] beyond 3 centimeters, they’re big. It’s a negative sign.”

The botched delivery of his grim diagnosis left Naito determined to share one final lesson with future physicians: Be careful how you tell patients they’re dying.

Since August, when he calculated he had six months to live, Naito has mentored medical students at Oregon Health & Science University and spoken publicly about the need for doctors to improve the way they break bad news.

“Historically, it’s something we’ve never been taught,” said Naito, thin and bald from the effects of repeated rounds of chemotherapy. “Everyone feels uncomfortable doing it. It’s a very difficult thing.”

Robust research shows that doctors are notoriously bad at delivering life-altering news, said Dr. Anthony Back, an oncologist and palliative care expert at the University of Washington in Seattle, who wasn’t surprised that Naito’s diagnosis was poorly handled.

“Dr. Naito was given the news in the way that many people receive it,” said Back, who is a co-founder of VitalTalk, one of several organizations that teach doctors to improve their communication skills. “If the system doesn’t work for him, who’s it going to work for?”

Up to three-quarters of all patients with serious illness receive news in what researchers call a “suboptimal way,” Back estimated.

“’Suboptimal’ is the term that is least offensive to practicing doctors,” he added.

The poor delivery of Naito’s diagnosis reflects common practice in a country where Back estimates that more than 200,000 doctors and other providers could benefit from communication training.

Too often, doctors avoid such conversations entirely, or they speak to patients using medical jargon. They frequently fail to notice that patients aren’t following the conversation or that they’re too overwhelmed with emotion to absorb the information, Back noted in a recent article.

“[Doctors] come in and say, ‘It’s cancer,’ they don’t sit down, they tell you from the doorway, and then they turn around and leave,” he said.

That’s because for many doctors, especially those who treat cancer and other challenging diseases, “death is viewed as a failure,” said Dr. Brad Stuart, a palliative care expert and chief medical officer for the Coalition to Transform Advanced Care, or C-TAC. They’ll often continue to prescribe treatment, even if it’s futile, Stuart said. It’s the difference between curing a disease and healing a person physically, emotionally and spiritually, he added.

“Curing is what it’s all about and healing has been forgotten,” Stuart said.

The result is that dying patients are often ill-informed. A 2016 study found that just 5% of cancer patients accurately understood their prognoses well enough to make informed decisions about their care. Another study found that 80% of patients with metastatic colon cancer thought they could be cured. In reality, chemotherapy can prolong life by weeks or months, and help ease symptoms, but it will not stop the disease.

Without a clear understanding of the disease, a person can’t plan for death, Naito said.

“You can’t go through your spiritual life, you can’t prepare to die,” Naito said. “Sure, you have your [legal] will, but there’s much more to it than that.”

The doctors who treated him had the best intentions, said Naito, who declined to publicly identify them or the clinic where they worked. Reached for verification, clinic officials refused to comment, citing privacy rules.

Indeed, most doctors consider open communication about death vital, research shows. A 2018 telephone survey of physicians found that nearly all thought end-of-life discussions were important — but fewer than a third said they had been trained to have them.

Back, who has been urging better medical communication for two decades, said there’s evidence that skills can be taught — and that doctors can improve. Many doctors bridle at any criticism of their bedside manner, viewing it as something akin to “character assassination,” Back said.

“But these are skills, doctors can acquire them, you can measure what they acquire,” he said.

It’s a little like learning to play basketball, he added. You do layups, you go to practice, you play in games and get feedback — and you get better.

For instance, doctors can learn — and practice — a simple communication model dubbed “Ask-Tell-Ask.” They ask the patient about their understanding of their disease or condition; tell him or her in straightforward, simple language about the bad news or treatment options; then ask if the patient understood what was just said.

Naito shared his experience with medical students in an OHSU course called “Living With Life-Threatening Illness,” which pairs students with ill and dying patients.

“He was able to talk very openly and quite calmly about his own experience,” said Amanda Ashley, associate director of OHSU’s Center for Ethics in Health Care. “He was able to do a lot of teaching about how it might have been different.”

Alyssa Hjelvik, 28, a first-year medical student, wound up spending hours more than required with Naito, learning about what it means to be a doctor — and what it means to die. The experience, she said, was “quite profound.”

“He impressed upon me that it’s so critical to be fully present and genuine,” said Hjelvik, who is considering a career as a cancer specialist. “It’s something he cultivated over several years in practice.”

Naito, who has endured 10 rounds of chemotherapy, recently granted the center $1 million from the foundation formed in his name. He said he hopes that future doctors like Hjelvik — and current colleagues — will use his experience to shape the way they deliver bad news.

“The more people know this, it doesn’t have to be something you dread,” he said. “I think we should remove that from medicine. It can be a really heartfelt, deep experience to tell someone this, to tell another human being.”


Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Is the Professionalism of Doctors, Nurses Being Exploited?

Doctors, nurses often do what’s right by their patients, even if it comes at a high personal cost. Is their professional nature being exploited by those in charge?

As the corporatization of healthcare continues at a rapid pace and staffing shortages march on, are the professionals at the heart of the health industry being exploited for their work ethic and professionalism? An op-ed published in The New York Times by Danielle Ofri, MD, PhD, an attending physician at Bellevue Hospital in New York City, postulates this to be true.

The op-ed, which points out that doctors and nurses often do the right thing for their patients, even though it frequently comes at a high personal cost, casts a scathing light on higher-ups who manipulate this to their favor. “If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage,” Dr. Ofri says in the piece.

Dr. Ofri goes on to point a blaming finger at time-consuming EHR, calling it the “biggest culprit of the mushrooming workload” that has been thrust upon medical professionals in recent years.

“For most doctors and nurses, it is unthinkable to walk away without completing your work because dropping the ball could endanger your patients,” Dr. Ofri states, which is the conundrum at the heart of the op-ed. Real lives are at stake, but not just those of the patients—the lives and livelihoods of those who care for them, too.

Read the op-ed in its entirety here, and tell us if you agree or disagree in the comments below.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

A Doctor Speaks Out About Ageism In Medicine

Doctors too often fail to appreciate older adults’ unique needs or to tailor treatments appropriately—one doctor envisions a different way of medicine.

Judith Graham, Kaiser Health News

Society gives short shrift to older age. This distinct phase of life doesn’t get the same attention that’s devoted to childhood. And the special characteristics of people in their 60s, 70s, 80s and beyond are poorly understood.

Medicine reflects this narrow-mindedness. In medical school, physicians learn that people in the prime of life are “normal” and scant time is spent studying aging. In practice, doctors too often fail to appreciate older adults’ unique needs or to tailor treatments appropriately.

Imagine a better way. Older adults would be seen as “different than,” not “less than.” The phases of later life would be mapped and expertise in aging would be valued, not discounted.

With the growth of the elder population, it’s time for this to happen, argues Dr. Louise Aronson, a geriatrician and professor of medicine at the University of California-San Francisco, in her new book, “Elderhood.”

It’s an in-depth, unusually frank exploration of biases that distort society’s view of old age and that shape dysfunctional health policies and medical practices.

In an interview, edited for clarity and length, Aronson elaborated on these themes.

Q: How do you define ”elderhood”?
Elderhood is the third major phase of life, which follows childhood and adulthood and lasts for 20 to 40 years, depending on how long we live.

Medicine pretends that this part of life isn’t really different from young adulthood or middle age. But it is. And that needs a lot more recognition than it currently gets.

Q: Does elderhood have distinct stages?
It’s not like the stages of child development — being a baby, a toddler, school-age, a teenager — which occur in a predictable sequence at about the same age for almost everybody.

People age differently — in different ways and at different rates. Sometimes people skip stages. Or they move from an earlier stage to a later stage but then move back again.

Let’s say someone in their 70s with cancer gets really aggressive treatment for a year. Before, this person was vital and robust. Now, he’s gaunt and frail. But say the treatment works and this man starts eating healthily, exercising and getting lots of help from a supportive social network. In another year, he may feel and look much better, as if time had rolled backwards.

Q: What might the stages of elderhood look like for a healthy older person?
In their 60s and 70s, people’s joints may start to give them trouble. Their skin changes. Their hearing and eyesight deteriorate. They begin to lose muscle mass. Your brain still works, but your processing speed is slower.

In your 80s and above, you start to develop more stiffness. You’re more likely to fall or have trouble with continence or sleeping or cognition — the so-called geriatric syndromes. You begin to change how you do what you do to compensate.

Because bodies alter with aging, your response to treatment changes. Take a common disease like diabetes. The risks of tight blood sugar control become higher and the benefits become lower as people move into this “old old” stage. But many doctors aren’t aware of the evidence or don’t follow it.

Q: You’ve launched an elderhood clinic at UCSF. What do you do there?
I see anyone over age 60 in every stage of health. Last week, my youngest patient was 62 and my oldest was 102.

I’ve been focusing on what I call the five P’s. First, the whole person — not the disease — is my foremost concern.

Prevention comes next. Evidence shows that you can increase the strength and decrease the frailty of people through age 100. The more unfit you are, the greater the benefits from even a small amount of exercise. And yet, doctors don’t routinely prescribe exercise. I do that.

It’s really clear that purpose, the third P, makes a huge difference in health and wellness. So, I ask people, “What are your goals and values? What makes you happy? What is it you are doing that you like best or you wish you were doing that you’re not doing anymore?” And then I try to help them make that happen.

Many people haven’t established priorities, the fourth P. Recently, I saw a man in his 70s who’s had HIV/AIDS for a long time and who assumed he would die decades ago. He had never planned for growing older or done advance care planning. It terrified him. But now he’s thinking about what it means to be an old man and what his priorities are, something he’s finally willing to let me help him with.

Perspective is the fifth P. When I work on this with people, I ask, “Let’s figure out a way for you to keep doing the things that are important to you. Do you need new skills? Do you need to change your environment? Do you need to do a bit of both?”

Perspective is about how people see themselves in older age. Are you willing to adapt and compensate for some of the ways you’ve changed? This isn’t easy by any means, but I think most people can get there if we give them the right support.

Q: You’re very forthright in the book about ageism in medicine. How common is that?
Do you know the famous anecdote about the 97-year-old man with the painful left knee? He goes to a doctor who takes a history and does an exam. There’s no sign of trauma, and the doctor says, “Hey, the knee is 97 years old. What do you expect?” And the patient says, “But my right knee is 97 and it doesn’t hurt a bit.”

That’s ageism: dismissing an older person’s concerns simply because the person is old. It happens all the time.

On the research side, traditionally, older adults have been excluded from clinical trials, although that’s changing. In medical education, only a tiny part of the curriculum is devoted to older adults, although in hospitals and outpatient clinics they account for a very significant share of patients.

The consequence is that most physicians have little or no specific training in the anatomy, physiology, pharmacology and special conditions and circumstances of old age — though we know that old people are the ones most likely to be harmed by hospital care and medications.

Q: What does ageism look like on the ground?
Recently, a distressed geriatrician colleague told me a story about grand rounds at a major medical center where the case of a very complex older patient brought in from a nursing home was presented. [Grand rounds are meetings where doctors discuss interesting or difficult cases.]

When it was time for comments, one of the leaders of the medical service stood up and said, “I have a solution to this case. We just need to have nursing homes be 100 miles away from our hospitals.” And the crowd laughed.

Basically, he was saying: We don’t want to see old people; they’re a waste of our time and money. If someone had said this about women or people of color or LGBTQ people, there would have been outrage. In this case, there was none. It makes you want to cry.

Q: What can people do if they encounter this from a doctor?
If you put someone on the defensive, you won’t get anywhere.

You have to say in the gentlest, friendliest way possible, “I picked you for my physician because I know you’re a wonderful doctor. But I have to admit, I’m pretty disappointed by what you just said, because it felt to me that you were discounting me. I’d really like a different approach.”

Doctors are human beings, and we live in a super ageist society. They may have unconscious biases, but they may not be malicious. So, give them some time to think about what you said. If after some time they don’t respond, you should definitely change doctors.

Q: Do you see signs of positive change?
Absolutely. There’s a much larger social conversation around aging than there was five years ago. And that is making its way to the health system.

Surgeons are thinking more and more about evaluating and preparing older adults before surgery and the different kind of care they need after. Anesthesiologists are thinking more about delirium, which has short-term and long-term impact on older adults’ brains. And neurologists are thinking more about the experience of illness as well as the pathophysiology and imaging of it.

Then you have the age-friendly health system movement, which is unquestionably a step in the right direction. And a whole host of startups that could make various types of care more convenient and that could, if they succeed, end up benefiting older people.


Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Physicians Enthusiastic about How AI Can Help Them with Digital Diagnostics

AI has the ability to change the landscape of modern medicine, and take some of the burden off of physicians, if used correctly.

by Alex Tate

AI can improve all aspects related to diagnostics of a practice easily. They can improve and assess results more practically and feasibly for practices and track disease and treatment response more accurately. This will assess and measure patient outcomes, and can free up doctor’s time and help with burnout. If the change is resisted it is because roles of clinicians will change.

AI can not only further digital diagnostics, but create new workflows that will change the current pace of diagnoses, prognoses and medical documentation. With accurate results, the less room for human error, and churning out a faster diagnosis can mean treating patients with care and better facilities. You can imagine why this may be met with enthusiasm for anyone in a white coat.

What will AI do in diagnostics?

  1. Increase lab report results.
  2. Overcome the current shortage of trained lab workers.
  3. Give accurate diagnosis in real time, without having to go through recurrent tests to rule out different diseases, illnesses, and diagnosis.
  4. Catch symptoms faster
  5. Cut down physician’s time spent looking at medical tests, scans, and spend more time treating a patient based on AI diagnosis.

AI is known to make significant contributions in radiology and pathology diagnostics. 75% of physicians are excited about advancements according to a research published in Digital Medicine (A. D. Shihab Sarwar, 2019). AI is beneficial for workflow efficiency and quality assurance in pathology. In the same research many physicians were welcoming towards training and other implications before AI can be used wholly in a practice. Pathology and radiology are image-focused and diagnostic-focused, and constant improvements in the computational algorithms for these specifications have been developed and powered for best outcomes. AI carries the potential to transform the clinical practice of physicians. In Pathology, AI diagnostics may perform image analysis for tissue histology, analysis of molecular outputs and predict the prognosis accurately.

Medical diagnostics are a category of medical tests designed to detect infections, conditions and diseases. AI is playing an integral role in the evolution of the field of medical diagnostics. Pathologists manually go through all blood types for diagnosis. AI in medical diagnostics is still a relatively new approach. Clinicians need convincing about how reliable, sensitive, and integrated it is in diagnostics. Why is that? A lot of reading, rigorous testing, and attention to detail is required in medical diagnostics. A mistake can be fatal. AI applications are created with precise computational algorithms that can effectively produce diagnostics in clinical practices.

Some clinicians are worried about what it means to them if a machine can read blood tests. It is likely to do a lot more. AI using neural networks can train diagnostic machines to understand the image. Pooled data is the way forward. Machine learning ensure that the machine picks up more information through pattern recognition.

AI can cut down time a physician spends on an EHR. Digital diagnostics can increase physician’s “pajama time” (late evening time spent with family or otherwise) if it performs all tasks. It also leads to a standardization in how data is interpreted by monitoring all lab information in real time. How does this do that? According to Mark Benjamin, the CEO of Nuance, the job of AI is not just to transfer voice text into written text, but it should also have the means to decipher text. That is the added advantage of Conversational AI. He explicates the four uses of healthcare industry; an evident improvement in a physicians’ life, enhanced quality of care and a discernibly healthier population, and a diminishing healthcare cost. Without technology (and AI), these goals cannot be actualized.

Physicians’ enthusiasm for improvements in AI functions in healthcare means that all manual readings and errors will visibly decrease. Saving possible time, lab use, money and easing compliance with government regulations is favorable to them. Virtual assistants are no longer a thing seen in Sci-Fi movies either. There are fast advances in AI. Every physician might be able to have their own “Jarvis” like Iron Man. Their job will be to save patients’ lives, like Tony Stark saves the planet. You don’t even have to imagine a “Jarvis” that is yours; the question is when will AI be yours.

Strong AI is still in the experimental stage. Documentation via voice recognition, and conversational AI prevents physician burnout and prevents it from relapsing. Clinical documentation will soon be able to write for itself, and have enough machine learning to predict text, symptoms and even diagnostics intelligently to cut further documentation time and perform data retrieval from EHRs quickly. AI is a workforce productivity tool and should be used as such to reduce time-intensive workflows. AI is also supposed to provide insights through Predictive and Prescriptive Analytics. Machine learning and Deep Learning (a distinct usage of machine learning) are method to achieve Artificial Intelligence.

Currently, physicians spend more time with their EHR charts than with patients. Even AI is no substitute for human touch or eye contact between caregiver and receiver. Medicine is an evidence-based profession and is rigid to change unless it does not see vast improvements in caregiving.

AI improves operations, with automating scheduling and billing. Clinical outcomes and decisions will still lie with the practice managers. Clinicians also like to see evidence before they believe how impactful AI is in their practice without taking away control. The idea for using AI in healthcare has never been to replace doctors, but rather to bring about support to health care delivery.

If AI can assist in diagnostics, robotic assisted surgery is not so far away. AI will be able to perform these tasks and many more with time. The only question is when. mHealth is joining in, and AI researchers say that it is only a matter of time until HQ mobile phone cameras will be able to understand images and send them to a database for further consideration.


Alex Tate is a Healthcare IT Researcher and freelance writer who focus various engaging and informative topics related to the health IT industry. He loves to research and write about topics such as Affordable Care Act, EHR, revenue cycle management, privacy and security of patient health data. You can reach him via email

Find out more about her company here: https://oxfordhousetherapy.com/

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Physician Burnout Costs U.S. Billions Each Year

Physician burnout is not only a widespread problem for physicians themselves, but it is also bad for business, or so found a new study published this week.

Physician burnout is not only a widespread problem for physicians themselves, but it is also, apparently, bad for business, or so found a new study published this week in the journal Annals of Internal Medicine.

Quantifying the toll of physician burnout has been tackled before, at least in terms of negative clinical and organizational outcomes, but the economic costs of this syndrome have not been as clear.

With this in mind, a team of researchers set out to tally the financial burden of burnout on physicians in the United States. They studied several vital measures related to physician burnout, including turnover rates and reduced clinical hours, as well as their associated costs, and used recent research and industry reports to come to a conservative, and yet, still staggering, estimated cost of burnout—$4.6 billion per year.

“Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians,” the study concluded.

While it is impossible to put a price on the lives of those who so often save lives in this country, having such an overwhelming estimated price tag attached to the problem may be what is needed for health care leaders to begin to adopt initiatives to remedy this ongoing issue.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Barton Associates’ Locum Hero: Dr. Neilly Buckalew

Earlier this year, Barton Associates announced the Locum Heroes campaign, with a focus on giving back to locum tenens providers who make a difference in their communities, near and far. In response, we received more than 100 nominations, each describing incredible stories of the ways that locum providers have spent their time on and between assignments. 

Neilly Buckalew, MD uses locum tenens work to have the flexibility to dedicate her free time as a volunteer for Honduras Hope Medical Mission. As a Barton Associates Locum Hero, Dr. Buckalew will receive a personal award of $2,500 and a donation of $2,500 will be given in her name to Pennsylvania-based, Honduras Hope Medical Mission for their 2019 mission trip.

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