Military hospitals better than civilian

[RichL025]

http://archinte.ama-assn.org/cgi/content/abstract/166/22/2511

On those (few) measured metrics, the authors concluded that federal / military hospitals gave better care.

With all the negativity around here about military medicine - it's nice to see some positive!

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[resxn]

I think I'd like to get the opinion from our EM docs on this, but here's why I think this may be the case.

The US military medical system is obsessed with metrics. Anything that can be quantified will be quantified. When a defined "best practice" exists with a pre-determined algorithm for treatment the military is going to be sure that that protocol is understood and followed in its facilities.

For the conditions described in the article, there are clear practice guidelines and therefore, the US military hospitals do well to provide better than average care for those patients.

If that is true, it does show that appropriate guidelines, when instituted in appropriate settings, can have a positive effect.

Regardless, bravo to EM physicians for getting it right.

And to the for-profit institutions: really? cutting corners? never would have thunk it.

 

[NavyFP]

http://archinte.ama-assn.org/cgi/content/abstract/166/22/2511

On those (few) measured metrics, the authors concluded that federal / military hospitals gave better care.

With all the negativity around here about military medicine - it's nice to see some positive!

In the end, despite all the negativity. We do OK.

 

[MedicalCorpse]

On those (few) measured metrics, the authors concluded that federal / military hospitals gave better care.

Did they include unsupervised interns running the ICUs at Andrews in their metrics?

Did they include zero anesthesia technicians at "Medical Centers" in their metrics? O.R. techs rotate through that position at Travis/Andrews/elsewhere. Most of the time, anesthesiologists have to be their own techs.

Did they include "triqualified" nurses running OB/postpartum/NICU (newborn nursery)?

Did they measure the time green military surgeons straight out of residency take to do lap choles, C-sections, or any other operative intervention (2-3 times longer than my civilian experience, with concomitantly increased risk to the patient due to prolonged surgery/anesthesia)?

How about the unsupervised CRNA Independent Providers of Extremely Competent Anesthesia Care (IPECAC) at major "Medical Centers" in all three services?

Have you ever read an OPR/EPR/FitRep that accurately reflected the incompetence of incompetent humans in the military?

When entire weeks of OR cases are set aside to buff the image of surgical services departments for HSI/JCAHO inspections, can you really believe any conclusions reached by those who are looking at the system from the outside in, rather than from the inside out?

Do you think that any civilian organization could possibly criticize military medicine in 2006-7 without being deluged by e-mail from anencephalic *****s castigating said organization for failing to "support our troops"?

When the entire system is set up to bamboozle JCAHO and other "metrics" oriented institutions, the only truth one should walk away with is this:

Garbage In, Garbage Out.

--
Rob Jones, M.D.
Ex-LtCol, USAF, MC
Ex-Anesthesia JCAHO "Champion", Travis AFB
Ex-Director of Quality Assurance, Andrews AFB

 

[DropkickMurphy]

Did they include unsupervised interns running the ICUs at Andrews in their metrics?

You had to bring that up didn't you? Just when the bad memories had started to fade.....

Have you ever read an OPR/EPR/FitRep that accurately reflected the incompetence of incompetent humans in the military?

Nope.....

 

[R-Me-Doc]

The US military medical system is obsessed with metrics. Anything that can be quantified will be quantified. When a defined "best practice" exists with a pre-determined algorithm for treatment the military is going to be sure that that protocol is understood and followed in its facilities.

For the conditions described in the article, there are clear practice guidelines and therefore, the US military hospitals do well to provide better than average care for those patients.

Absolutely. These guidelines and our MTF's degree of compliance were reviewed monthly at the command level.

X-RMD

 

[FliteSurgn]

Did they measure the time green military surgeons straight out of residency take to do lap choles, C-sections, or any other operative intervention (2-3 times longer than my civilian experience, with concomitantly increased risk to the patient due to prolonged surgery/anesthesia)?

My average time for a lap chole straight out of residency was 15-20 minutes. In my experience, the "green" surgeons were faster than the experienced military surgeons because they had let their skills atrophy for a longer period of time. The senior surgeon at our base routinely took 3 hours for a lap chole and 2-3 hours for a lap inguinal hernia. My lap hernia time is around 30 minutes for a unilateral and 45 min for bilateral.

I may be an anomaly, but in general, green surgeons are going to be green whether they are in the military or not. The real difference is that in the civilian sector, at some point they become "seasoned" while in the military they just get a darker shade of green.

 

[militarymd]

JCAHO is ALL about the ILLUSION of good care....not actually good care.....any GOOD clinician knows that....

Then there are the clinicians who create the illusion of good care.

 

[orbitsurgMD]

JCAHO is ALL about the ILLUSION of good care....not actually good care.....any GOOD clinician knows that....

Then there are the clinicians who create the illusion of good care.

JCAHO and the military were a bi-annual charade. I remember once at my clinic they issued new, clean and starched white coats just for the visit day which they promptly collected the minute the inspectors were gone.

 

[DiveMD]

JCAHO and the military were a bi-annual charade. I remember once at my clinic they issued new, clean and starched white coats just for the visit day which they promptly collected the minute the inspectors were gone.

White coats.. I haven't seen one of those in a while...

 

[The White Coat Investor]

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[pgg]

Military residencies also score well on in-service exams, another useless metric.

Objective tests of knowledge, created by specialty boards and administered nationwide under controlled conditions, are useless?

 

[resxn]

Objective tests of knowledge, created by specialty boards and administered nationwide under controlled conditions, are useless?

Yes.

Is a test really useful if your specialty board automatically fails the bottom 5% of test takers, regardless of score as some of them do?

Most boards are "minimal competency" tests, yet they test you on esoteric trivia at least on the MCQ's, because they want to separate those who really know their stuff from those who may know most but not all of their stuff.

I think a much better test of knowledge and safety for minimal competency are the oral portion of board exams, but not every specialty has that. Mine do, and although many people struggle because of stress and not a lack of knowledge, I think you have a better chance of demonstrating you are a safe and effective physician in those situations.

I've see plenty of doctors who suck like no other who can score in the 240's on USMLE's and who can ace board exams. I've seen plenty who have average scores who are great physicians. How does a multiple choice test tell you who will thrive in an airway emergency, or any other for that matter? It won't. That's been demonstrated in studies over and over again.

 

[Ex-44E3A]

it speaks to the difference between book learning and experience.

I've taught all kinds of residents, many quite bright, but some lacked that "clinical gut" or gestalt. It's part of the "art" of medicine that you only gain by clinical experience. Some people, brilliant evidence-based, study-quoting gods they may be, never quite develop that clinical eye.

It's why you pay attention when that 20-year-veteran ICU nurse calls you in the middle of the night. You may know more book knowledge than her, but she's got 20 years of patient care under her belt, and that experienced clinical eye is often dead-on. She might not know exactly what's wrong... but she definitely knows that something's going haywire.

I don't think test score are necessarily useless, but there's far, far more to medicine that board scores.

 

[resxn]

it speaks to the difference between book learning and experience.

I've taught all kinds of residents, many quite bright, but some lacked that "clinical gut" or gestalt. It's part of the "art" of medicine that you only gain by clinical experience. Some people, brilliant evidence-based, study-quoting gods they may be, never quite develop that clinical eye.

It's why you pay attention when that 20-year-veteran ICU nurse calls you in the middle of the night. You may know more book knowledge than her, but she's got 20 years of patient care under her belt, and that experienced clinical eye is often dead-on. She might not know exactly what's wrong... but she definitely knows that something's going haywire.

I don't think test score are necessarily useless, but there's far, far more to medicine that board scores.

Completely agree. And would add this one additional example.

I teach a lot of residents in the OR and the one thing I've found for people, whether they're surgical techs, med students, residents, or attendings. Some people just get surgery--they get how to differentiate tissue in a bloody field, they instinctively have a feel for how to hold their hands, they know where to throw a suture, they know how hard or soft to retract, they understand instinctively when and where to grab tissue. It's not based on education, but it is certainly improved with experience. Some people just get it from the get-go.

I think there is that inherent quality in any field. Michael Jordan worked his tail off, but he had a lot more talent built in than many others. Some docs have a feel for disease, for presentation, for knowing how to take a quick yet precise history, how to operate, or how to act in an emergency. Some need to learn it. Some never fully get it. But a standardized test in even the most controlled situation will never be able to quantify the quality of a physician.

 

[basicscikills]

Your reasoning is correct. We always laughed at the JCAHO guidelines at my previous institution. Some of them are good...gotta give an ASA to an MI patient, have to give antibiotics to a PNA patient within 4 hours (i.e. before he goes upstairs etc.) Some are silly...have to do a blood culture on a patient with a PNA despite the fact that no study has ever shown it affects outcomes and it rarely affects antibiotic decisions.

The main problem is that these are measured by JCAHO at discharge, not at admission. So if the patient has positive troponins noted at any time during the hospitalization, JCAHO goes back to see if the ED gave him an ASA. Never mind what his EKG and troponin was in the ED or even if he had chest pain (or dyspnea, or nausea, or jaw pain or hypotension or whatever in the ED.) If he is admitted with undiagnosed dyspnea and leaves the hospital 14 days later with 27 diagnoses and one of those happens to be pneumonia....ding, the hospital loses a point. The only way to fight it is to order blood cultures without regard to cost or medical necessity.

Hardly a method of judging the quality of a hospital. The emergency medicine professional organizations are taking an active hand in formulating better guidelines/metrics/quality indicators etc... so hopefully this will improve in the future.

But I'm not surprised military hospitals scored well on these. Military residencies also score well on in-service exams, another useless metric.

I think JCAHO is a whole lot like ISO 9000 in the nonmedical business world. If you've never been through one of those inspections, they basically want a documented procedure for everything your company does, from selling and shipping your product to how the bathrooms are cleaned. You pay a whole bunch of cash to the ISO 9000 inspector, churn out reams of paperwork, then get to advertise your company as being ISO 9000 certified. Does that mean you deliver a better product or service?

Similarly, JCAHO has become, alone with Medicare, the 900 pound gorilla of medicine. Just about everyone I talk with in the medical community hates JCAHO, but nobody is willing to really do anything about it. At the hospital where I spend most of my med student time, we periodically institute new measures that are completely useless in our particular situation, cost an incredible amount of money, and are of extremely dubious value in improving patient outcomes, but are mandated by the JCAHO inspector. Our performance in these new "quality measures" are then broadcast to the general public as evidence of the quality of care at our facility as compared to other hospitals. Never mind that as a city hospital, we don't have the staffing that the for profit hospitals do, nor the resources. Never mind that in my own experience in some of those other hospitals, I've seen uninsured patients with potentially fatal conditions undertreated or outright chucked out the door. Obviously the care somewhere else is better, because they give all their patients with a possible pneumonia antibiotics within four hours of admission.

Our hospital staff wants us to have patients fill out surveys to assess the quality of their care. There's a lot of brinksmanship that goes on with the surveys though, as the nurses often "forget" to mention them to drug seekers, angry family members, etc. Still, we proudly post our 97% patient satisfaction rate on our quarterly performance reports. Does that really mean anything? Of course not.

I therefore seriously question any statistically based measure of the quality of care (or the quality of a doctor) whenever I see one. What I've found, for the most part, is that a tremendous amount of time and resources that could be spent seeing patients instead is spent, for the most part, filling out reams of documentation that often is completely unrelated to the patient in question. Given that the military and government in general is famous for paperwork, I find it likely that even more time is wasted meeting metric goals and less time taking care of patients, therefore I question whether it is even remotely possible within the system to give a better quality of care.

 

[The White Coat Investor]

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[r90t]

In LA (Los Angeles, not the flooded, rural state with bad care), within 10 mile radius of downtown (not going south/central), there are a number of hospitals that are "for profit" and very bad. They have a reputation for poor care and archaic equipment. To top it off, they take care of insured middle to upper-middle class asian americans. They have the financial means to go elsewhere, but stay within their community based hospital system. My wife toured one this week and said it made a county health system look good.

Our non-military physicians on this board may be at fine hospitals, but there are some that are not up to the standards of America's worst military facility.