quinta-feira, 31 de julho de 2014
Entrevistado do vídeo da postagem anterior confirma retorno à Porto Alegre
Será em outubro e como palestrante do mês em nossas atividades do Programa de Medicina Hospitalar no Hospital Divina Providência. Mais informações em breve.
quarta-feira, 23 de julho de 2014
Confundem hospitalistas
Ainda há muito trabalho de promoção do conceito a ser feito.
Em hospital onde atuo como intensivista, recentemente fui convidado para palestrar na principal atividade científica. Assunto: Time de Resposta Rápida. Indiquei colegas com maior experiência. Houve certa insistência, eu havia sido bem recomendado, afinal de contas era ou não era expert em hospitalistas????
Trata-se de histórica confusão entre hospitalistas e TRR, já discutida em:
Em hospital onde atuo como intensivista, recentemente fui convidado para palestrar na principal atividade científica. Assunto: Time de Resposta Rápida. Indiquei colegas com maior experiência. Houve certa insistência, eu havia sido bem recomendado, afinal de contas era ou não era expert em hospitalistas????
Trata-se de histórica confusão entre hospitalistas e TRR, já discutida em:
Depois outros disseram-me que poderia ter usado da experiência na implantação de TRR no HDP, que deveria ter aceitado igual. O fato é que o evento ficou melhor assim:
segunda-feira, 21 de julho de 2014
Algumas mensagens de hospitalistas norte-americanos para mim, ao longo destes anos…
Divulgação de textos ou depoimentos daqueles que iniciaram e promoveram a MH nos EUA é fundamental para melhor aproveitamento do modelo em nosso meio (parte 1)
de Robert Wachter, 2010
"I present to you a few thoughts on hospital medicine and the role that “hospitalists” play in the United States. Of course, your local environments are not identical to the USA environment, but I believe the basic dynamics and the potential for hospital medicine are the same. It is my perception that Brazil is now at a stage that was prevalent in the US about ten years ago, with respects to hospitalists and the role that they play. At that time, the concept of physicians dedicated to hospital medicine was fairly new, and many in the medical community viewed this development with alarm and suspicion. There were many myths and fears that were soon swept aside by the realities of the benefits of hospital medicine. I present some of the more common fears to you, along with a more current view of the reality in the US.
Myth:
Hospitalists will steal my patients.
Reality:
Hospitalists are dedicated inpatient clinicians. They do not have outpatient practices. They can assume primary care for patients while they are in the hospital, but depend on community physicians to provide post hospitalization care. Generally, use of hospital medicine services in voluntary.
Myth:
I will lose prestige and money if I use hospitalists to provide care for my hospitalized patients.
Reality:
The early reluctance to use hospitalists in the US has largely disappeared, as evidenced by the astronomical growth of the hospital medicine movement here. Much of the growth of hospital medicine in the US is fueled by the advantages they provide to community physicians, surgeons, and sub-specialists. These groups soon realized that they could work much more efficiently in their office or consultative settings when they did not have to go from the office to the hospital setting every day, take care of patients in the middle of the night, or go to several hospitals in a day. The reimbursement for their relatively small inpatient practice was not worth the travel time and time lost from their core work. Patients appreciated having a physician that was very familiar with the inner workings of the hospital available to them for more the day. Providing that their primary care provider and hospitalist communicate and explain their respective roles, patient satisfaction with the arrangement is very good.
Myth:
Hospitalists should restrict their work to urgent / emergent needs of inpatients when I am not physically present.
Reality:
Hospitalists are uniquely positioned to take comprehensive care of the inpatient with complex problems. Their availability is only one of the reasons why they produce better outcomes than non-hospitalists in study after study. They are vested in making the hospital environment and the systems of care better and safer for patients and staff. They ‘own’ rather than ‘rent’ the use of the hospital and the complex systems within it, and are rapidly assuming leadership roles in all manner of quality and safety initiatives. They are constantly focused on protocols and the standardization of care in their work environment, and the modern medical center needs this kind of focus to improve their overall patient outcomes.
I suggest you find a good hospitalist group and make sure you have a communication plan worked out, and just try the arrangement on a few of your patients… you’ll soon see the advantages for yourself. C’mon in, the water is just fine.
Regards.
Greg Maynard MD, MSc
Clinical Professor of Medicine and Chief, Division of Hospital Medicine
University of California, San Diego"
de Robert Wachter, 2010
"It is gratifying to watch the growth of the hospitalist movement in Brazil. As you know, the field has grown remarkably quickly in the US, and it is now the fastest growing specialty in American medical history. Its growth has been driven by both research and experience documenting that strong hospitalist programs lead to improved quality, efficiency, and medical education. Moreover, with the increasing emphasis on improving systems of care, hospitalists came along at precisely the right time: their focus on both the care of individual patients and on making hospital systems work better is now considered the leading edge of an attitude we're trying to promote in all our physicians.
Early on, many hospitalists in the United States complained that they were not considered full-fledged physicians; some talked about being treated like "super-residents." Although I still hear this complaint from time to time, it is now fairly unusual. Most physicians, hospitals, and patients have recognized the central role of hospitalists in direct care and coordination, and hospitalists have assumed their role at the center of many systems. In fact, increasing numbers of hospitalists are assuming leadership positions. At the University of California, San Francisco (UCSF), for example, hospitalists in my group are now the Associate Chief Medical Officer, the Medical Director for Information Technology, and the Associate Chair for Safety and Quality (in addition to a number of other important roles). This is one small window into the fact that our hospitalists are now considered full-fledged, highly respected members of the medical staff.
This transition is natural; while there are things that hospitalists can and should do to move it along, it is the natural evolution of a specialty, as it transitions from new idea into a mature field with well trained specialists, separate certification, and widespread recognition of its value. Hospitalists bring such value to all of the parties: primary care doctors, specialists, hospital leaders, and most importantly, patients. It is just a matter of time before this value is fully recognized in Brazil.
-- Bob Wachter"
1st, community physicians were not willing to take call to cover the emergencies at their hospitals. Hospitals were forced to hire hospitalists to assume responsibility for "unassigned patients" in the emergency department. Community physicians did not complain about this because this was taking a burden off of them.
In parallel with this, managed care oversight impacted the amount of inpatient "business" for community physicians. With fewer and fewer patients in the hospital (and those that were in the hospital being complex, sick patients), the economics of doing inpatient care became less desirable for community physicians. In a slow but steady fashion, community physicians began to refer their patients to hospitalists.
In addition, 2 other "forces" impacted the growth of hospital medicine. 1) At teaching hospitals, resident work hours were limited by new national policy. Thus, hospitalists had to be hired to assume to front line responsibility for patient care at teaching hospitals. 2) Multi-specialty group practices made the decision to implement hospitals because they saw it as a superior model and one that made sense economically and from a lifestyle perspective.
Thus, although there was outright hostility to hospitalists in the early days, once a program is implemented at a given hospital, often the most vocal critics change their minds within relatively short periods of time.
Early on, many hospitalists in the United States complained that they were not considered full-fledged physicians; some talked about being treated like "super-residents." Although I still hear this complaint from time to time, it is now fairly unusual. Most physicians, hospitals, and patients have recognized the central role of hospitalists in direct care and coordination, and hospitalists have assumed their role at the center of many systems. In fact, increasing numbers of hospitalists are assuming leadership positions. At the University of California, San Francisco (UCSF), for example, hospitalists in my group are now the Associate Chief Medical Officer, the Medical Director for Information Technology, and the Associate Chair for Safety and Quality (in addition to a number of other important roles). This is one small window into the fact that our hospitalists are now considered full-fledged, highly respected members of the medical staff.
This transition is natural; while there are things that hospitalists can and should do to move it along, it is the natural evolution of a specialty, as it transitions from new idea into a mature field with well trained specialists, separate certification, and widespread recognition of its value. Hospitalists bring such value to all of the parties: primary care doctors, specialists, hospital leaders, and most importantly, patients. It is just a matter of time before this value is fully recognized in Brazil.
-- Bob Wachter"
de Joseph A. Miller (Senior Vice President, Society of Hospital Medicine), 2008
"Hospital Medicine has grown as a marketplace phenomena, not because of any mandate. A few things drove this development here:1st, community physicians were not willing to take call to cover the emergencies at their hospitals. Hospitals were forced to hire hospitalists to assume responsibility for "unassigned patients" in the emergency department. Community physicians did not complain about this because this was taking a burden off of them.
In parallel with this, managed care oversight impacted the amount of inpatient "business" for community physicians. With fewer and fewer patients in the hospital (and those that were in the hospital being complex, sick patients), the economics of doing inpatient care became less desirable for community physicians. In a slow but steady fashion, community physicians began to refer their patients to hospitalists.
In addition, 2 other "forces" impacted the growth of hospital medicine. 1) At teaching hospitals, resident work hours were limited by new national policy. Thus, hospitalists had to be hired to assume to front line responsibility for patient care at teaching hospitals. 2) Multi-specialty group practices made the decision to implement hospitals because they saw it as a superior model and one that made sense economically and from a lifestyle perspective.
Thus, although there was outright hostility to hospitalists in the early days, once a program is implemented at a given hospital, often the most vocal critics change their minds within relatively short periods of time.
Good luck!
JOE"
JOE"
de Gregory Maynard, UCSD, 2008 (C’mon in, the water is just fine)
Myth:
Hospitalists will steal my patients.
Reality:
Hospitalists are dedicated inpatient clinicians. They do not have outpatient practices. They can assume primary care for patients while they are in the hospital, but depend on community physicians to provide post hospitalization care. Generally, use of hospital medicine services in voluntary.
Myth:
I will lose prestige and money if I use hospitalists to provide care for my hospitalized patients.
Reality:
The early reluctance to use hospitalists in the US has largely disappeared, as evidenced by the astronomical growth of the hospital medicine movement here. Much of the growth of hospital medicine in the US is fueled by the advantages they provide to community physicians, surgeons, and sub-specialists. These groups soon realized that they could work much more efficiently in their office or consultative settings when they did not have to go from the office to the hospital setting every day, take care of patients in the middle of the night, or go to several hospitals in a day. The reimbursement for their relatively small inpatient practice was not worth the travel time and time lost from their core work. Patients appreciated having a physician that was very familiar with the inner workings of the hospital available to them for more the day. Providing that their primary care provider and hospitalist communicate and explain their respective roles, patient satisfaction with the arrangement is very good.
Myth:
Hospitalists should restrict their work to urgent / emergent needs of inpatients when I am not physically present.
Reality:
Hospitalists are uniquely positioned to take comprehensive care of the inpatient with complex problems. Their availability is only one of the reasons why they produce better outcomes than non-hospitalists in study after study. They are vested in making the hospital environment and the systems of care better and safer for patients and staff. They ‘own’ rather than ‘rent’ the use of the hospital and the complex systems within it, and are rapidly assuming leadership roles in all manner of quality and safety initiatives. They are constantly focused on protocols and the standardization of care in their work environment, and the modern medical center needs this kind of focus to improve their overall patient outcomes.
I suggest you find a good hospitalist group and make sure you have a communication plan worked out, and just try the arrangement on a few of your patients… you’ll soon see the advantages for yourself. C’mon in, the water is just fine.
Regards.
Greg Maynard MD, MSc
Clinical Professor of Medicine and Chief, Division of Hospital Medicine
University of California, San Diego"
domingo, 20 de julho de 2014
Perversidades decorrentes de um modelo de remuneração maluco
Hospitalistas brasileiros inovando. Para ver muitos pacientes (quantos assim precisariam permanecer internados?), criaram um carimbo que facilita o registro diário...
sexta-feira, 11 de julho de 2014
Hospitalistas em absoluto destaque para países de língua portuguesa
Walter Mendes, da Fiocruz, deu-me a oportunidade de contribuir em módulo intitulado Comunicação entre profissionais de saúde e a segurança do paciente.
Quando convidou-me, perguntei sobre a possibilidade de inserir o tema hospitalista. Ele então lembrou o quanto defendo a qualidade e a segurança nas passagens de informações, ao mesmo tempo em que defendo que estas passagens ocorram o mínimo necessário (handoff e handover só são bons mesmo para quem vende ferramentas de otimização - na vida real são maus necessários, por vezes nem tanto). E recordou que sempre bato na importância de 01 médico como responsável maior pelo paciente hospitalizado - o coordenador médico do cuidado hospitalar. Eis que disse: será neste módulo que promoveremos também o conceito do hospitalista - através da sugestão de equipes coesas e com o médico literalmente junto, da comunicação preferencialmente presencial do médico nas diversas interfaces possíveis do ambiente hospitalar.
Pois é com intensa satisfação que poderei, através de capítulo do livro didático do curso internacional, apresentar o hospitalista para profissionais da saúde do Brasil, de Portugal, dos PALOPs (Países Africanos de Língua Oficial Portuguesa) e do Timor-Leste. Provavelmente atingiremos pessoas que nunca ouviram falar sobre o modelo. Pessoalmente, nunca imaginei levar isto para tão longe.
Quando convidou-me, perguntei sobre a possibilidade de inserir o tema hospitalista. Ele então lembrou o quanto defendo a qualidade e a segurança nas passagens de informações, ao mesmo tempo em que defendo que estas passagens ocorram o mínimo necessário (handoff e handover só são bons mesmo para quem vende ferramentas de otimização - na vida real são maus necessários, por vezes nem tanto). E recordou que sempre bato na importância de 01 médico como responsável maior pelo paciente hospitalizado - o coordenador médico do cuidado hospitalar. Eis que disse: será neste módulo que promoveremos também o conceito do hospitalista - através da sugestão de equipes coesas e com o médico literalmente junto, da comunicação preferencialmente presencial do médico nas diversas interfaces possíveis do ambiente hospitalar.
Pois é com intensa satisfação que poderei, através de capítulo do livro didático do curso internacional, apresentar o hospitalista para profissionais da saúde do Brasil, de Portugal, dos PALOPs (Países Africanos de Língua Oficial Portuguesa) e do Timor-Leste. Provavelmente atingiremos pessoas que nunca ouviram falar sobre o modelo. Pessoalmente, nunca imaginei levar isto para tão longe.
quarta-feira, 9 de julho de 2014
O manifesto de Romário e as bases da corrupção
Em um texto grande que pode ser lido na íntegra aqui, Romário diz:
"… A corrupção da CBF tem raízes em todos os clubes brasileiros, vale lembrar que são as federações e clubes que elegem há anos o mesmo grupo de cartolas, com os mesmos métodos de gestão arcaicos e corruptos implementados por João Havelange e Ricardo Teixeira e mantidos por Marin e Del Nero. Vale lembrar, que estes dois últimos mudaram o estatuto da entidade e anteciparam a eleição da CBF para antes da Copa. Já prevendo uma possível derrota e a dificuldade que eles teriam de se manter no poder com um quadro desfavorável.
E os clubes? Sim, eles também são responsáveis por essa crise. Gestões fraudulentas, falta de investimento na base, na formação de atletas. Grandes clubes brasileiros estão falindo afogados em dívidas bilionárias com bancos e não pagamentos de impostos como INSS, FGTS e Receita Federal.
E toda essa má gestão que tem destruído o nosso futebol, infelizmente, tem sido respaldada há anos pelo Congresso Nacional…"
E toda essa má gestão que tem destruído o nosso futebol, infelizmente, tem sido respaldada há anos pelo Congresso Nacional…"
Enquanto muitos estão apontando o dedo para a CBF, no seu mundinho permitem, direta ou indiretamente, práticas semelhantes.
Corrupção não tem solução. Mas como seria melhor se houvesse menor tolerância a ela por terceiros mesmo quando os resultados das práticas pelas pessoas que a executam também os beneficiam. Havia escrito sobre isto aqui. Romário ilustra com maestria.
Neste sistema onde há concessões, permissividade e relativização por quem não faz diretamente, mas se aproveita do resultado final, não consigo ver o corrupto como muitos costumam. É apenas o mais corajoso de um grande grupo.
Neste sistema onde há concessões, permissividade e relativização por quem não faz diretamente, mas se aproveita do resultado final, não consigo ver o corrupto como muitos costumam. É apenas o mais corajoso de um grande grupo.
segunda-feira, 7 de julho de 2014
Reações adversas a medicamentos: um problema negligenciado?
por Maria Angélica Pires Ferreira, médica, membro executivo da Comissão de Medicamentos (COMEDI) e Simone Mahmud, farmacêutica, chefe do Serviço de Farmácia. Coordenadora do programa de Uso Seguro de Medicamentos. em BOLETIM QUALIS/HCPA nº2 Junho de 2014
Reações adversas a medicamentos (RAM) são definidas pela Organização Mundial da Saúde (OMS) como “qualquer efeito nocivo e não intencional que ocorre após a administração de um medicamento em doses normalmente utilizadas pelo homem para profilaxia, diagnóstico ou tratamento de uma enfermidade”.
Os dados na literatura sobre a epidemiologia das RAM são subestimados devido à falta de registros em prontuários clínicos e à dificuldade de diagnóstico, sendo que a maioria dos estudos que determinam a prevalência de RAM são prospectivos. Uma meta-análise que englobou 39 estudos prospectivos demonstrou que a incidência global de reações adversas graves foi de 6,7% (IC 95%, 5,2% - 8,2%) e de reações fatais foi de 0,32% (IC 95%, 0,23% -0,41%) dos pacientes hospitalizados.
Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients. BMJ 2004; 329 doi: http://dx.doi.org/10.1136/bmj.329.7456.15
Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-analysis of Prospective Studies. Jason Lazarou, MSc; Bruce H. Pomeranz, MD, PhD; Paul N. Corey, PhD. JAMA 1998;279(15):1200-1205.
Apesar de serem comuns, as RAM frequentemente passam despercebidas. Isso ocorre em parte devido à dificuldade de diferenciá-las de outros problemas clínicos, mas também pode representar a falta de conscientização sobre o problema, cuja busca e identificação não está instituída de forma sistematizada na rotina assistencial. Dessa forma, principalmente em pacientes graves, que fazem uso de múltiplos medicamentos, a ocorrência de sinais e sintomas inexplicados, ou deterioração clínica inesperada, deve-se estar atento para a possibilidade de as manifestações serem decorrentes de RAM.
O Hospital de Clínicas tem um processo estabelecido de farmacovigilância que realiza busca ativa de RAM por meio de registro em prontuários. Durante os mais de dez anos de acompanhamento, tem se verificado que o processo de registro em prontuários é deficitário, dificultando a identificação e notificação de RAM. Para ilustrar, em 2014 houve 17 registros de RAM, sendo quatro delas consideradas graves e uma fatal. Os principais medicamentos relacionados foram: cefepime, heparina, sacarato de hidróxido de ferro e clozapina.
A falta de registro em prontuário representa um problema tanto em nível individual, no que se refere à assistência, ao dificultar a comunicação e a avaliação do caso entre os membros da equipe, como também um problema em nível sistêmico, uma vez que as RAM não são identificadas corretamente na instituição a fim de se tomarem medidas cabíveis com vista à prevenção e controle. Metodologias alternativas de busca de RAM estão sendo consideradas do ponto de vista institucional para que possam ser identificadas precocemente. No entanto, o registro das RAM no prontuário é fundamental para o desenvolvimento de ações preventivas.
quarta-feira, 2 de julho de 2014
Inscrições "reparadoras" para o Congresso Brasileiro de Médicos Hospitalistas / Rio de Janeiro
Foram encaminhadas esta semana mensagens a todos aqueles que se associaram em entidade criada por mim no passado, durante minhas gestões, investindo dinheiro e depositando confiança no projeto. O futuro da organização a eles deveria ter pertencido, mas individualmente sabem do que foram privados. Alguns e-mails voltaram. Como tenho cópia de todas as planilhas da época, bem como de comprovantes de pagamentos, sintam-se a vontade para entrar em contato através de medicinahospitalar@gmail.com e solicitar sua inscrição promocional.