International Hospital Medicine

Pulling the Welcome Mat Out from Under Our Colleagues

We sat in the living room at a colleague’s home, drinking beer, wine or sparkling water, eating desserts, and talking. Talk started with residents comparing notes about clinical sites or rotations, worries about being prepared for boards, congratulations on fellowship matches, and discussions about trying to decide what to do post-residency. “How are you doing?” my colleague and assistant residency program director asked the group. Silence followed. One person spoke up. “I’m worried about what will happen with my fellowship. I’m still talking with my lawyer.” This was not a question of where he would match, how his clinical skills would be stretched, or adapting to a new location. This was about his immigration status. We met two weeks after the president’s executive order on immigration, and he was worried if he would be able to continue to work under his current visa, being from one of the seven countries…

US Versus Foreign Trained Docs: Who Saves More Lives?

Yeah, I know the headline drew you in.  I sleuthed ya---but I have a reason. A study out in BMJ today, and its timing is uncanny given the immigration ban we are now experiencing. First, to declare my priors. I will take an IMG to work by my side any day of the week.  You need to be twice as smart, motivated, and industrious to make your way to American shores. The paper:   The researchers analyzed data on 1.2 million hospital admissions of Medicare patients aged 65 and over between 2011 and 2014 and for 44,227 internists. The average age of patients was 80, and the most common causes of death were sepsis, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease. The difference in results was slight, but I post the tables if only to show, at least based on this sample set, at worst, IMGs are equal to, and best,…

On Swiss Cheese and Patient Safety

Professor James Reason is the intellectual father of the patient safety field. I remember reading his book Managing the Risks of Organizational Accidents in 1999 and having the same feeling that I had when I first donned eyeglasses: I saw my world anew, in sharper focus. Reason’s “Swiss cheese” model, in particular – which holds that most errors in complex organizations are caused not so much by the inevitable human mistakes but rather by the organization’s incomplete layers of protection, which allow the errors to pass through on their way to causing terrible harm – was an epiphany. It is the fundamental mental model for patient safety, as central to our field as the double helix is to genetics. Last month, I returned to England to give a couple of talks, one at a conference called “Risky Business,” the other at the UK’s National Patient Safety Congress. The former brings…

The Patient Will Rate You Now

These days, I’d never consider trying a new restaurant or hotel without reading the on-line ratings on TripAdvisor or Yelp. I seldom even bother with professional restaurant or travel critics. Until recently, there was little patient-generated information about doctors, practices or hospitals to help inform patient decisions. But that is rapidly changing, and the results may be every bit as transformative as they have been in traditionally consumer-centric industries like hospitality. Medicine has never thought much of the wisdom of crowds, but the times, as the song goes, they are a-changin’. Even if one embraces the value of listening to the patient, several questions arise. Should we care about the patient’s voice because of its inherent value, or because it can tell us something important about other dimensions of quality? How best should patient judgments be collected and disseminated – through formal surveys or that electronic scrum known as the…

A Pay Within a Play: The Awkward World of Private Insurance in the UK

I remember reading an article that observed that systems of universal insurance – which need to put their energy into providing a “decent minimum” for the masses – must also offer a “safety valve for the wealthy disaffected.” Canada bans private insurance for basic hospital and medical care services. So, when affluent Canadians want “the best,” some of them pop across the border to Cleveland or Ann Arbor. But from the time of its founding in 1948, the British National Health Service has allowed – and, depending on which party is in power, promoted – a private insurance market. Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. Here’s how it works: The insurance part isn’t too difficult to understand. People living in Britain can obtain private insurance, and about…
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