The Patient as Precedent: Stare Decisis and the Collapse of the Scientific Method.

The Stare decisis of Medicine is the Scientific Method and the Stare decisis of the Scientific Method is Debate over any knowledge claim involving the patient. COVID-19 has threatened the orthodoxy of the Scientific Method with a new orthodoxy - Medicine as political purpose. Among the many examples involve origins, immunity and lockdowns. In each of these the patient-as-judge may declare a mistrial. Only Medicine can restore trust through the legal doctrine of Completeness.

The Patient as COVID: The Destructive Bias of Politicized Science - Flashpoints, Obligations and the Burden of Coming Together.

Within an unrelenting COVID-19 pandemic, the burden of helping without harming has grown under the weight of destructive political bias which is harming without helping. This pandemic has created three flashpoints surrounding patient, population and policy. As science is further politicized, the coronafication of medicine is now a subset of the politicization of everything and is challenging these obligations. It is not the presence of personal political bias which degrades science, it is the absence of institutional acknowledgment as conflict of interest. Physicians must interrogate in Socratic fashion, seven deadly sins of destructive bias - character assassination, raw animus, cynical omniscience, historical amnesia, false choice, divisive labelling and selective truthing, which undermine our coming together. At a time when public trust is at risk, we must defend the best interest of the patient against politicized science - for this bias has reached the bedside.

The Patient as Obligation - The Binary Failure of "Privilege" vs. "Right" Part 2 - My Privilege - From The Great Equation to An American Sickness to Mac and Cheese for All to An American Idea.

"Privilege" vs. "Right" in healthcare is a failed political binary because it has divided the nation. The "my privilege" end of this false choice has been damaging, shifting the burden to the patient and away from the physician. It is medicine's historic privilege to care for any human but obligation has waned being plagued by opportunism. Also, what we have a right to or are privileged to receive is undefined. Past premises for the privilege are untrue, based on Health = medical care. Present assessments of the privilege are unfair, deeming American medicine a sickness. Future solutions for the privilege are untenable, if "equality" is the goal. The framework for healthcare's obligation-to-give already surrounds us, emerging from the American Revolution with its idea of individual dignity as to priority, checks and balances as to protection and Federalism as to improvement. American medicine has followed this idea albeit misused and unfulfilled. The null hypothesis of this debate must be fairly tested - that American medicine is the worst form of healthcare delivery - except for all the rest. Both Big Business and Big Politics in healthcare have become ends unto themselves and therefore neither can solve the privilege question nor bear the weight of our obligation-to-give. The patient-as-obligation must be our aim.

Insidious Blastomycoses Osteomyelitis in a Young, Immunocompetent Male.

Blastomyces is a fungus that is endemic to the Ohio and Mississippi River Valleys and Great Lakes region. The fungus is a rare cause of infection, but most commonly causes infections of the lungs followed by the skin and bones. Infection of the bone is often not clinically suspected, which can slow the diagnosis. In this report, we present a case of Blastomyces osteomyelitis in a young, immunocompetent male.

The Patient as Human - Fiduciary Redefined.

Trust in American culture is under siege being pulled up from the roots by impermanence, distance and animus. Trust in medicine will shrivel in similar ways unless rooted in the intrinsic worth of the human as foundation and as manifested by the intrinsic nature of the human as kindness. The sacred trust of the patient redefines "fiduciary" as advocacy, which inspires trust by standing in behalf of the beneficiary with kindness. We must re-plant healthcare in the patient as human - or reap the withering of our industry.

The Patient As Team: American Indian Healthcare and the Transorganization - A Shout for Leadership.

American Indian health care in the state of South Dakota meets the definition of a humanitarian crisis and as such is being called a third-world country within its own borders. This dizzying challenge will require an out-ofthe-box but previously successful Transorganization, to address a problem which will never be solved by separate organizations operating in silos. It will also require visionary leadership to shine a permanent light on this conundrum, inviting all physicians and healthcare systems to join together as a team of teams, until this situation is transformed. The urgency of this matter demands much more than the typical call for leadership. It demands a shout.

The Patient as Obligation - The Binary Failure of "Privilege" vs. "Right" Part 1 - My Right - Sez Who?

Privilege vs. Right in healthcare is a failed binary because it has divided the nation. The "my right" end of the false choice has been confusing, because it portrays obligations as rights. Further, it rhetorically attempts to grant a right where none exists. Of central concern is the question of authority and from where it arises. With the proffered death of God comes the death of any transcendent set of propositions about right and wrong. Every person then becomes a "godlet" being tempted to exert authority over other godlets, prompting the response, "Sez who?" The claim that "healthcare is a right" strives to redefine the terms of authority in healthcare but must answer the same question, "Sez who?" Efforts to anchor a right to healthcare in posited law fail because there is no such right either explicitly or implicitly enumerated in the Constitution. Further, the stretch to ground a right to healthcare as "inalienable" also fails because inalienable rights (life, liberty, and the pursuit of happiness) are not forced but rather protected. The Affordable Care Act of 2010 attempted to force such a right through mandatory purchase of insurance - and so unraveled. Appeals to this right based on "moral obligation" are laudable but fall back to the same question, "Sez who?" The Natural Law, as a transcendent ought pulls from within every civilization and system of thought - and answers such a question not as human right but as human obligation. The Natural Law, as the common moral ground therefore has the gravitas to command our allegiance and be the authoritative foundation for healthcare reform.

The Patient as Reformation - Here We Stand Part Three - Legitimate Authority and True Reform.

Healthcare delivery in the U.S is in the midst of a social crisis and demands social reform. Physician-reformers must understand that the roots of this dilemma lie in a loss of legitimate authority, as it extends to the patient. Legitimate authority in medicine exists when patient-centeredness leads - with self-less advocacy that strengthens the patient bond, radical accountability that restores the public trust and extraordinary teamwork that addresses exploding complexity. Absent these, authority is simply an exercise of power. Physician-reformers must stand on the ground of patient-centeredness and debate the truth-claims of patient-centered reform.

The Patient as Reformation - Here We Stand Part One - The Incredible Shrinking Patient.

The U.S. is currently embroiled in a divisive healthcare reform debate. It is therefore important to understand how the principles of reformation might embolden the development of physician-reformers, who are willing to step out as advocates. Martin Luther, who heavily influenced reformers like Martin Luther King, Jr., set the standard for reformation on the singular idea of legitimate authority - rooted in the inestimable worth of the person. Patient-centeredness is that singular truth for healthcare and is the only cure for the incredible shrinking patient, who is being diminished by powers far stronger than it.

The Patient as Reformation - Here We Stand Part Two - A Reformer Among Us.

All social reform, as evidenced by Martin Luther, requires disrupters who are willing to speak truth to power. Donald Berwick, as the most Lutheresque figure in the healthcare reform debate, has been doing just that, having defined the singular truth of patient-centeredness and its implications for both the regulated and unregulated parts of medicine. He has consequently been asking wicked questions concerning unproven assumptions, such as competition driven by the integer, over cooperation driven by the immortal. Above all he is reminding physicians of our dual role - clinical healer and social advocate - and that silence in the latter, is no longer an option. Physician-reformers must follow Berwick through this opened door and apply the principles of reformation, on behalf of the patient.

Decreasing the critical value of hemoglobin required for physician notification reduces the rate of blood transfusions.

Red blood cell transfusions have been cited as one of the most overused therapeutic interventions in the USA. Excessively aggressive transfusion practices may be driven by mandatory physician notification of critical hemoglobin values that do not generally require transfusion. We examined the effect of decreasing the critical value of hemoglobin from 8 to 7 g/dL at our institution. Along with this change, mandatory provider notification for readings between 7 and 8 g/dL was rescinded. Transfusion rates were compared retrospectively during paired 5-month periods for patients presenting in three key hemoglobin ranges (6.00-6.99, 7.00-7.99, and 8.00-8.99 g/dL). A change in transfusion practices was hypothesized in the 7-8 g/dL range, which was no longer labeled critical and for which mandated physician calls were rescinded. Transfusion rates showed a statistically significant 8% decrease (P≤0.0001) during the 5-month period post change in our transfusion practices. This decrease in the 7.00-7.99 g/dL range was significantly greater than the 2% decrease observed in either the 6-6.99 g/dL (P=0.0017) or 8-8.99 g/dL (P≤0.0001) range. Cost savings of up to $700,000/year were extrapolated from our results showing 491 fewer units of red blood cells transfused during the 5-month post change. These cost savings do not take into account the additional impact of complications associated with blood transfusions.

Comparison of Content and Format for Upper Respiratory Illness Antibiotic Prescribing Guideline Developed by Two Midwestern Organizations.

Antimicrobial resistance is a rapidly emerging public health problem, largely due to antibiotic prescribing which lacks an evidence base. We previously reported the results of local efforts within a single healthcare system at devising clinical guidelines to reduce unnecessary and even inappropriate antibiotic prescribing. This paper presents a comparison of the antibiotic guidelines developed by that process with those released by Institute for Clinical Systems Improvement, a national clinical quality organization. We found that the content of the guidelines are comparable, but not identical, while the formats differed, fitting separate but overlapping niches.

"Heart Bone"--The Case for the IHI Open School as Connector: A Model for Integrating Quality Improvement and Patient Safety into Health Professions Curricula.

BACKGROUND: The physician is guardian of the patient and obligated to both the "Science of Medicine" (SOM), defined by the randomized controlled trial, and the "Art of Medicine" (AOM), defined by patient safety (PS) and quality improvement (QI). Historically SOM knowledge has dominated AOM knowledge; however given the frequency of medical harm, a new paradigm is necessary. The Institute for Healthcare Improvement Open School (IHIOS) is accelerating AOM into medical curricula by connecting all stakeholders to the emerging PS and QI sciences, and doing so in an interprofessional manner. METHODS: A South Dakota IHIOS chapter was established in 2011, connecting SOM to AOM knowledge for 600 students from eight schools and thirteen disciplines. Four specific foci included 1) interprofessional pilot project introducing PS and QI into first year curricula, 2) sessions for third-year medical students to assess Open School courses through faculty-facilitated small groups, 3) development of longitudinal quality and safety curricula, 4) integration of OS courses across South Dakota health professions schools. RESULTS: The interprofessional pilot project demonstrated significant learning in 16 of 16 and 13 of 16 (p = 0.05) teaching points. The third-year sessions showed that PS and QI topics are viewed as important especially with faculty-facilitated case studies. Subsequently a longitudinal PS and QI curriculum was implemented. This led to the incorporation of IHIOS courses as core curricula in four South Dakota colleges and eight health disciplines. CONCLUSIONS: Our work was one of the first large-scale efforts to measure learning via the IHIOS through the novel use of the chapter as connector. The model contributes to national efforts for paradigm change through interprofessional education.

Building a whole new mind: an interprofessional experience in patient safety and quality improvement education using the IHI Open School.

INTRODUCTION: Throughout the last decade, there has been a significant move toward integrating patient safety and quality improvement concepts into health professions education, essentially building a whole new mind in terms of medical knowledge. While existing literature has suggested possible means of implementation, little research has described outcomes and specific examples of integration. The Institute for Healthcare Improvement (IHI) Open School offers a curriculum that could be incorporated in most health professions training. This project serves to study implementation of Open School courses, garner student feedback and guide the implementation of quality and safety curricula across health disciplines in South Dakota. METHODS: First-year medical and allied health students at the University of South Dakota completed surveys before and after having one introductory lecture and finishing two of the Open School courses in interprofessional teams within an existing health professions course. RESULTS: Medical student means showed significant differences in 16 of 16 (p=0.05) primary teaching points related to Open School course objectives, while allied health students showed significant differences in 13 of 16 (p=0.05) points. Students valued an introductory lecture and thought their educational experience was enhanced by the addition of the Open School courses. CONCLUSION: Our results demonstrate that the Open School courses chosen for this sample of interprofessional students provide a simple, inexpensive and effective method to implement quality and patient safety concepts within existing health professions curricula.

What ever happened to the common cold? Improving antibiotic utilization.

Unnecessary antibiotic prescribing has tremendous cost to both the individual and to society in terms of drug resistance, adverse drug reactions and economic expense. There is overwhelming evidence in the medical literature that the majority of outpatient cases for which antibiotics are prescribed may be effectively and safely treated without the use of these agents. We present algorithms for upper respiratory tract infections to aid physicians and advanced practice clinicians in distinguishing those patients who may benefit from antibiotics from the greater majority who are more likely to be harmed by them.